MARCH 2014 VOL. 32, NO.

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NEWSBITES
Natural Labeling for GMOs Puts FDA in Middle

he US Food and Drug Administration (FDA) nds itself in the middle of the tussle over whether foods labeled as natural can contain genetically modied (GMO) ingredients. The Grocery Manufacturers Association is petitioning the agency to specically authorize natural labeling on GMO products, such as those containing bioengineered corn, soy, canola or sugar. The trade association cited the proliferation of lawsuits challenging natural labeling, with 65 pending classaction cases across the country. At the same time, three federal judges presiding over such cases have asked the FDA to rule on whether GMO ingredients belong in natural foods. Current FDA regulations state only that natural products cannot contain added color, articial avors or syn-

Daily Handful of Nuts Linked to Lower Mortality Risk

Study nds nuts can be a healthful contributor to your diet.

ating a daily handful of nutsabout one ounce or three tablespoonscould reduce your risk of dying from the most common causes of death. Results from the largest study of its kind, following nearly 119,000 men and women for up to 24 years, show that regular consumers of any type of nuts were less likely to die from heart disease, cancer and lung disease or from all causes than non-nut eaters. As frequency of nut consumption went up, mortality risk dropped. This is a good study, comments Jerey Blumberg, PhD, director of Tufts HNRCA Antioxidants Research Laboratory and co-author of a recent review of the evidence for nuts health benets (see the May 2012 newsletter Special Supplement). As with most good research, it is an incremental and logical next step in the continuing investigation of the health benets of this food group.

TAKE CHARGE!

CRACKING NUTS BENEFITS: Why are nuts

NEWSBITES continued on page 2

INSIDE
2 NEWSBITES: Food safety, 2014 trends, trans fats and more. 3 Risk from too much phosphorus. 4 SPECIAL REPORT: Are you wasting your money on multivitamins? 6 New doubts about D beyond bones. 7 Exercise combats chronic conditions. 8 ASK TUFTS EXPERTS: Yerba mat tea, alcohol and bones, and more. 4-PAGE SPECIAL SUPPLEMENT: The truth about the war on wheat.

good for you? Nuts are rich in healthy unsaturated fats, protein and ber and vitamin E and low in carbohydrates, Blumberg explains. The total antioxidant capacity of a serving of nuts is comparable to one of broccoli or tomatoes. Previous studies have linked nut consumption to improvements in cholesterol, blood pressure and blood-sugar control, among other benets that might underlie the mortality ndings. Although nuts are also high in calories, ranging from 160 to 204 calories per ounce, the new research found that more-frequent nut eaters actually tended to be leaner. Theres a general percep-

o add a daily handful of nuts to your diet, start by simply reaching for your favorite nuts instead of snacking on chips, sweets or other less-nutritious choices. Other ways to eat more nuts include: Top green salads with nuts instead of cheese or meats. Sprinkle on low-fat yogurt, ice cream or frozen yogurt. Add to steamed vegetables or vegetable stir-fries. Use ground nuts to thicken sauces. Substitute ground nuts for some of the flour in baked goods. Because of their high fat content, nuts can quickly go bad if not stored properly. Keep in an airtight container in your refrigerator or a sealed plastic bag in your freezer; dont store near foods whose odors might be absorbed by the nuts.

tion that if you eat more nuts youre going to get fat, commented lead researcher Ying Bao, MD, ScD, of Brigham and Womens Hospital in Boston. Our results show the opposite. Other studies have reported similar results. Says Blumberg, Some of the fat in nuts is not actually digested and so does not contribute to actual calorie intake as much as would be calculated from the contentand, thus, the lack of association with nut consumption and overweight/obesity; indeed, there is a slight inverse correlation between the two. Also, several
NUTS continued on page 3

NEWSBITES
continued from page 1

Editor Irwin H. Rosenberg, MD University Professor Managing Editor David A. Fryxell Recipe Editor Patsy Jamieson FRIEDMAN SCHOOL
Robin B. Kanarek, PhD, Professor, Nutrition and Behavior; Interim Dean Mark Krumm, Director of Communications

EDITORIAL ADVISORY BOARD

Jerey B. Blumberg, PhD, Professor; Senior Scientist and Director, Antioxidants Research Laboratory Bess Dawson-Hughes, MD, Professor of Medicine, Endocrinology; Senior Scientist and Director, Bone Metabolism Laboratory Alice H. Lichtenstein, DSc, Senior Scientist and Director, Cardiovascular Nutrition Laboratory; Stanley N. Gershoff Professor of Nutrition Joel B. Mason, MD, Professor, Nutrition and Medicine; Senior Scientist and Director, Vitamins and Carcinogenesis Laboratory Miriam E. Nelson, PhD, Professor Helen M. Rasmussen, PhD, RD, Instructor; Senior Research Dietitian, Metabolic Research Unit Susan B. Roberts, PhD, Professor, Nutrition and Psychiatry; Senior Scientist and Director, Energy Metabolism Laboratory Robert M. Russell, MD, Emeritus Professor, Nutrition and Medicine
Jean Mayer USDA Human Nutrition Research Center on Aging The Friedman School gratefully acknowledges ongoing support for research and education from John Hancock Financial Services, Inc. Tufts University Health &Nutrition Letter (ISSN 1526-0143) is published monthly for $36 per year by Tufts University. Managed by Belvoir Media Group, LLC. 2014 Tufts University.

thetic substances, and that the labeling term must not be used in a misleading way. The Grocery Manufacturers Association argued, There is no material dierence between foods derived from biotechnology and their traditional counterparts. There is nothing synthetic or articial about foods derived from biotechnology as that term has been applied by the agency. The FDA has not responded to the petition, but told the judges it would respectfully decline their request for administrative guidance. (For more on the pros and cons of GMOs, see our November Special Report.)

by others double dipping chips, serving food thats fallen on the oor, forgetting to wash hands and leaving perishables unrefrigeratedeven though we do all those things ourselves. And such errors have consequences: 43% said theyd gotten sick after a dinner party or other food gathering away from home.

Postmaster: Send address corrections to PO Box 8517, Big Sandy, TX 75755-8517

Editorial Correspondence Tufts University Health &Nutrition Letter POBox 5656, Norwalk, CT 06856-5656 Subscriptions $36 per year (US). $43 per year (Canada) Single copies of back issues $5 each. For subscriptions and customer service information, write: Tufts University Health &Nutrition Letter PO Box 8517, Big Sandy, TX 75755-8517 Call toll-free: 800-274-7581 Online Customer Service www.nutritionletter.tufts.edu Disclaimer: This newsletter is not intended to provide advice on personal health matters, which should be provided by a qualified health care provider. We regret that we cannot respond to individual inquiries about personal health care. We occasionally make our subscriber names available to carefully screened organizations whose publications and services may interest our subscribers. If youd rather not receive such mailings, please send your mailing label, or a copy, with instructions to: the Customer Service Address at above. Express written permission is required to reproduce, in any manner, the contents of this issue, in full or in part. For more information, write Tufts University Health &Nutrition Letter, POBox 5656 Norwalk, CT 06856-5656. Printed in USA. Canada Publishing Agreement Number: 40739143

ook for more worries about wheat and increasing interest in ancient grains, kale, coconut oil and chia seeds as 2014 goes on. Thats the forecast from a survey of more than 500 registered dietitians conducted by Todays Dietitian and Food Companies Exceed Pollock Communications. Calorie-Cutting Goal The dietitians also preince 2007, 16 of the nadicted a continuing decline Kale: still on the menu in 2014. (Image tions leading food and in low-fat dieting, while Thinkstock) beverage companies have eco-friendly eating will cut 6.4 trillion calories out of the American be on the rise. Overall, the experts expect a dietequivalent to 78 daily calories per growing interest in health information, with person. Thats the conclusion of a report consumers looking to blogs and TV doctors by the Robert Wood Johnson Foundation, as well as dietitians; supermarket dietitian which worked with the companies to help is the fastest-growing job classication in combat childhood obesity. The rms had grocery stores. (For more on wheat, see this originally pledged to slash 1 trillion calories issues Special Report. We covered chia seeds by 2010, and a foundation spokesman said he and kale in the March and July 2013 newsletwas encouraged by the progress beyond that ters, respectively.) goal: Now we hope that others see the success these companies have had and make the FDA Extends Trans Fat Comment Deadline same commitment. Participating producers ook for the next step in the FDAs account for more than a third of all packaged proposed crackdown on trans fats to food and beverage sales, by total calories. come this spring, as the agency extended its It wasnt clear, however, how much of comment period on the rule to March 8. Late the calorie reduction was due to consumlast year, the FDA proposed revoking the ers simply buying less during the recession, fats status as generally recognized as safe rather than manufacturers reformulation of (GRAS), which would lead to a phase-out of their products. trans fats in most food products. Food companies had asked for an extension beyond Fessing Up on Unsafe Food Handling the original Jan. 7 comment deadline, citing hen it comes to safe food handling for the complexity of the issue, and are expected parties and other gatherings, Amerito push for alternatives to a ban such as cans motto seems to be: Do as I say, not as enhanced labeling or a maximum threshold. I do. A new Kitchen Pet Peeve Survey by Trans fats, typically in the form of partially NSF International nds a double standard hydrogenated vegetable oils, are convenient in attitudes about food for a crowd, with for food packagers and restaurants but have 82% admitting to food-safety mistakes when been linked to heart disease; the fats increase preparing for others but 96% oended when unhealthy LDL cholesterol while lowering others make the same slips. Were turned o good HDL cholesterol levels.

Dietitians Predict Nutrition Trends

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Does Your Diet Deliver Too Much Phosphorus?

One-third of Americans may be getting more than the recommended amount.

TAKE CHARGE!

hosphorus, a mineral found in foods such as meat and milk, is important for forming bones and teeth, making proteins for healthy cells, and transporting cellular energy. But too much of a good thing can be harmful among people with kidney disease, and a new study suggests excess phosphorus consumption is associated with increased mortality risk, even in people with normal kidney function. The danger of too much dietary phosphorus may be on the rise because of the growing popularity of phosphorusbased additives in packaged foods. These phosphate compounds are employed as preservatives, anti-caking agents, stabilizers, leavening agents and acidiers. A second study (see box) recently reported that nearly half of the bestselling grocery products in the United States contain phosphorus additives. In an analysis of dietary data, more than one-third of American adults were found to consume in excess of 1,400 milligrams of phosphorus dailydouble the RDA and apparently enough to increase their mortality risk. When intake of phosphorus chronically exceeds nutrient needs, there is a disruption in the endocrine regulation of phosphorus balance, explains Madhumathi Rao, MD, an assistant

professor at Tufts University School of Medicine. A trade-o takes place, with the elevation of hormones that force the excretion of phosphorus by the kidney, but at the expense of the eects of these hormones on tissues. The consequences are calcium deposition in the blood vessels, enlargement of the heart, bone loss and progression of kidney disease. While these consequences are readily apparent in individuals with kidney disease often in the setting of abnormally elevated serum phosphorus, they are also seen in healthy individuals without an overt elevation of serum phosphorus.

f you want to avoid consuming too much phosphorus, it pays to cook more of your meals from scratch rather than relying on packaged foods. According to a study in the Journal of Renal Nutrition, 44% of the most popular grocery items in the US contain phosphorus additives. The products most likely to contain such additives were: Prepared frozen foods Dry food mixes Packaged meats Bread and baked goods Soups

ADDITIVES ADD UP: The latest study, pub-

lished in the American Journal of Clinical Nutrition, looked at data on 9,686 healthy US adults, ages 20 to 80, who participated in a national nutrition survey (NHANES III). Over a followup period of 12 to 18 years, those whose diets meant they consumed more than 1,400 milligrams of phosphorus daily were at increased risk of dying from any cause. Because of the prevalence of high phosphorus intake in healthy adults and the widespread use of inorganic phosphorus additives in processed food, our ndings may have public health implications, concluded Alex R. Chang, Professionals Follow-Up Study of men. During the follow-up period of 20 to 24 years, 27,429 participants died. Those who ate nuts at least daily were 20% less likely to die of all causes than those eating no nuts. The reduced risk was most apparent for deaths from heart disease (29%), followed by deaths from cancer and lung disease. Participants ate all types of nuts, including peanuts, which are legumes and not true tree nuts but have a similar nutrient prole. An analysis found no signicant dierence in mortality benet between types of nuts. The study was supported by the

MD, of Geisinger Health System, and colleagues. Some experts believe that even those high levels of phosphorus consumption are understated, because its dicult for calculations to account for all food additives. Food manufacturers do not always supply complete information on such additives. On food labels, these appear as ingredients with the word phosphate or ending in phosphate, as well as phosphoric acid. People are not generally aware of the importance of avoiding phosphorus overload or of the need to inspect food labels more carefully, says Tufts Dr. Rao. Poor quality foods and fast foods, often consumed by individuals with lower socioeconomic status, have the highest phosphorus content from food additives. National Institutes of Health and the International Tree Nut Council Nutrition Research and Education Foundation (which had no role in designing the study or reporting the results). As an observational study, the ndings cant prove cause and eect. But Dr. Bao said she was very condent the observations reect a true benet from nut consumption, adding, We did so many analyses, very sophisticated ones to eliminate other possible explanations for nut eaters reduced mortality risk. Possible confounding factors the study eliminated included smoking status, exercise habits and diabetes.
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studies indicate that nuts are particularly satiating, so people tend to eat less during a subsequent meal or snack. Nonetheless, its still a good idea to substitute nuts for less-healthy foods, such as chips and cookies or salad toppings. Nuts can also stand in for meat and even help thicken sauces. (See box.)

ALL TYPES OF NUTS: The new research,

published in the New England Journal of Medicine, combined data from two large observational studiesthe Nurses Health Study of women and the Health

MARCH 2014

SPECIALREPORT

Are You Really Beneting from Your Multivitamins?

A new task-force report and two studies say evidence of benet lacking.

ouve seen the TV commercials. A daily multivitamin supports heart and breast health, boosts your immune system and protects your eyes. A smiling couple feel pretty darned smart after learning that a study showing multivitamins reduce cancer risk used the very brand shes been making him take. That TV-commercial couple might be smiling a little less these days. A new nding from the same study reports no benet from a daily multivitamin against cognitive decline. Another study says multivitamins were no better than placebo in protecting patients whove suered a heart attack. In a draft report, the US Preventive Services Task Force recently concluded that theres not enough evidence to tell whether supplements, including multivitamins, reduce the average persons risk of cancer or heart disease. And in an editorial accompanying the two studies, ve experts stated atly, Evidence is sucient to advise against routine supplementation, and we should translate null and negative ndings into action. Enough is enough. Are the estimated 40% of American adults who take a daily multivitamin simply wasting their money? Irwin H. Rosenberg, MD, editor of the Tufts University Health & Nutrition Letter, says, Seven decades after we learned to synthesize vitamins and package them as multivitamins for insurance against nutritional shortfalls, we still too often dene our nutritional status in terms of what vitamin supplements we use. Over and over again, weve seen that obtaining nutrients from supplements does not confer the same benets as consuming a well-chosen diet.

Medicine. One looked at data from the Physicians Health Study II, which had previously shown a modest reduction in cancer risk associated with multivitamin usebut no protection against cardiovascular events (not mentioned by those TV ads). This analysis focused on cognitive function, combining ve tests of global cognitive function as well as testing verbal memory. Participants were 5,947 men, average age 71.6, who were randomly assigned to either a daily multivitamin or a placebo. Over an average follow-up of 8.5 years, changes in mental function were no dierent in the multivitamin group than those taking a placebo. Researchers Francine Grodstein, ScD, of Brigham and Womens Hospital in Boston, and colleagues concluded, These data do not provide support for use of multivitamin supplements in the prevention of cognitive decline. They noted, however, that multivitamins may have other benets, such as the previously reported association with cancer risk. Moreover, since the study focused on physicians, who tend to have healthy diets and be well-nourished, the multivitamins may not have made much dierence in their overall nutrient status. Grodstein added that she thinks there is room for more research, although she conceded the challenges of such studies: We dont and probably never will have randomized trial data over decades.

CASE CLOSED?: The second new study, led

NO BRAIN BENEFIT: Both new studies

were published in the Annals of Internal

by Gervasio Lamas, MD, of Mount Sinai Medical Center in Miami Beach, focused on patients who had previously suered a heart attack. Data came from the TACT

study, conducted at 134 centers across the US and Canada, and involved 1,708 mostly male patients, average age 65. The study looked at total deaths, cardiovascular deaths, recurrent heart attacks, stroke, coronary revascularization and hospitalization for angina. After an average follow-up of 4.6 years, there was no signicant dierence between patients randomly assigned to a daily multivitamin or placebo, either overall or for any specic measure. Nor was there any evidence of harm from taking the multivitamins, with only a slightly higher rate of adverse events among that group. In the editorial accompanying the two studies, Eliseo Guallar, MD, DrPH, of the Johns Hopkins Bloomberg School of Public Health, and colleagues interpreted the dual ndings as the nail in the con for supplement use: Other reviews and guidelines that have appraised the role of vitamin and mineral supplements in primary or secondary prevention of chronic disease have consistently found null results or possible harms. The message is simple: Most supplements do not prevent chronic disease or death, their use is not justied, and they should be avoided. This message is especially true for the general population with no clear evidence of micronutrient deciencies, who represent most supplement users in the US and in other countries. The unusually blunt editorial continued, Although available evidence does not rule out small benets or harms or large benets or harms in a small subgroup of the population, we believe that the case is closedsupplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benet and might even be harmful. The Natural Products Association, a supplements trade organization, reacted with shock to what they termed an attack on their $30 billion industry. Our members market and sell their products in order to assist people to achieve a

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SPECIALREPORT
healthier lifestyle, a spokesman said.

BEHIND THE NUMBERS

The percentages in the Supplement Facts box on labels of multivitamins and other supplements (as well as in Nutrition Facts labels on food) are calculated using the Daily Value (DV) for each nutrient. Recommended intakes of nutrients vary by age and gender and are known as Recommended Dietary Allowances (RDAs) and Adequate Intakes (AIs). One value for each nutrient is selected as the DV; the DV is often, but not always, similar to ones RDA or AI for that nutrient. These recommendations for healthy people do not reect special requirements for those with diseases or chronic conditions.

EVIDENCE LACKING: A few days before,

the US Preventive Services Task Force (USPTF) had dealt an only somewhat softer blow to the supplement industry. In a draft of an update to its 2003 advice, the USPTF found inadequate evidence to recommend either for or against vitamin and mineral supplementation, including multivitamins, for the primary prevention of cardiovascular disease or cancer. The task force is an independent, volunteer panel of national experts that makes reports to Congress; its expected to issue its nal report on supplements later this year. The recommendations apply to healthy adults without nutrient deciencies. The draft also rearmed advice against beta-carotene supplements, because of lack of benet and evidence of increased lung-cancer risk among smokers, and added a recommendation against vitamin E supplements. There is a clear lack of benet, according to the expert panel, for vitamin E against either cardiovascular disease or cancer. Despite ndings from two trials, including the Physicians Health Study II, showing a slightly lower risk of cancer among men taking multivitamins, the USPTF said the evidence wasnt strong enough to recommend the pills for cancer prevention. Stephen P. Fortmann, MD, of the Kaiser Center of Health Research, who led the USPTF evidence review, told the New York Times that vitamin purchasers may be throwing their money away. He added, Dont think it makes up for a bad diet, that you can eat a lot of fast food and then take a bunch of supplements. Thats not a good idea.

TOO LITTLE, TOO MUCH: Only a handful

of individual supplemental nutrients have been shown in rigorous testing to have real benets, including some that certain people cant obtain adequately from dietary sources. These include the AREDS formula of antioxidants for people at risk of macular degeneration, folic acid for pregnant women to prevent spina bida

and other neural-tube defects in their children, and synthetic vitamin B12 (as a supplement or in fortied foods) for older adults who dont produce enough stomach acid to separate natural B12 from food. Some people, especially premenopausal women, may also need extra iron. In their editorial, Dr. Guallar and colleagues single out vitamin D as another supplement on which the jury is still out. Tufts Dr. Rosenberg explains, Targeted individual vitamin supplements have established benets for those with diseases or conditions which impose special nutrient requirements. These benets are usually achieved by doses higher than those in multivitamin supplements. Multivitamins may help supply these nutrients, but more often they dont contain enoughand in the case of folic acid may add up to too much. Heres a look at each: Antioxidants for eyesClinicaltrial data from the Age-Related Eye Disease Study (AREDS) supports a formulation of 500 milligrams (mg) of vitamin C, 400 International Units (IU) of vitamin E, 10 mg lutein, 2 mg zeaxanthin, 80 mg of zinc as zinc oxide and 2 mg of copper as cupric oxide for those at risk for age-related macular degeneration (AMD)the leading cause of blindness among older Americans. Most multivitamins contain much lower amounts of these nutrients. Even multivitamins sold as specially formulated for vision health are mostly inadequate for obtaining the proven amounts. (Compare, for example, one leading brand that delivers only 90 mg vitamin C, 60 IU

vitamin E and 15 mg of zinc.) Folic acidWhile vital for women who are or might become pregnant, folic acid (the supplement form of folate) in excess might enhance the risk of cancer, according to research by Tufts Joel Mason, MD. The amount in a typical multivitamin (about 400 micrograms) isnt enough to exceed the 1,000 mcg upper limit set by the Institute of Medicine. But Dr. Mason cautions that combining a multivitamin with fortied cereal or energy bars, plus a B-complex supplement, could put someone at risk. Vitamin B12Most multivitamins deliver 10 times or more of the daily recommended 2.4 mcg of vitamin B12; theres no danger to getting extra, but no proven benet, either. Older adults at risk of deciency can easily obtain enough synthetic B12, which is more readily absorbed, from fortied cereal and other fortied foods or from supplements. IronWhile premenopausal women often need extra iron, the recommendation for women over 50 and adult men is only 8 mg daily. Multivitamins formulated for older adults typically omit ironcheck the labelbecause of the risk of iron overload. Vitamin DEssential for bone health, vitamin D can be dicult to obtain in adequate amounts from food alone. With age, the body also loses some of its natural ability to make vitamin D in the skin from sun exposure. The 400 IU in a typical multivitamin might be just what you need to tip the scales, but most studies showing a bone-health benet from supplemental vitamin D have tested higher amounts. (For more on vitamin D, see page 6.) Before you decide to take a daily multivitamin, just in case, check the Supplement Facts label carefully and consider any other supplements and fortied foods you consume. More of any individual nutrient isnt necessarily better, and may not even be safe. Make sure your physician knows about what supplements youre taking, and discuss any health concerns before counting on a multivitamin as a cure-all.

MARCH 2014

New Questions About Benets from Vitamin D Beyond Bones

D FOR DIABETES PREVENTION?

So far, randomized trials fail to back up benets seen in observational studies.

D, on the other hand, were less likely to suer cardiovascular events, diabetes and colorectal cancer. But when put to the test in intervention trials of vitamin D supplementation, extra vitamin D failed to reduce the risk of disease occurrence or progression, or to benet all-cause mortality. The exception was supplementation of 800 IU in a group of older patients, mostly women, which did slightly reduce all-cause mortality. Publishing their ndings in The Lancet Diabetes & Endocrinology, Dr. Autier and colleagues observed, The discrepancy between observational and intervention studies suggests that low 25(OH)D [a measure of vitamin D levels in the blood] is a marker of ill health. Inammatory processes involved in disease occurrence and clinical course would reduce 25(OH)D, which would explain why low vitamin D status is reported in a wide range of disorders. In elderly people, restoration of vitamin D decits due to aging and lifestyle changes induced by ill health could explain why low-dose supplementation leads to slight gains in survival.

f youve been popping vitamin D supplements for benets beyond bone healthsuch as preventing heart disease, cancer or diabetesits too soon to know if those pills are really doing you any good. Thats the lesson, experts say, from a sweeping new review of 290 observational studies and 172 randomized trials of vitamin D, chronic disease and mortality. Although vitamin D deciency was associated with a variety of health problems in the observational studies, the trials in which participants were actually given extra vitamin D failed to prove a benet. This apparent paradox could be because the doses of extra vitamin D tested were too low to make a dierence; the largest trial in the review, the Womens Health Initiative, tested supplements of only 400 International Units (IU). Its also possible, however, that vitamin D deciency is a sign of poor health status, rather than a cause of or contributor to chronic disease. To me the takeaway is that we dont yet have randomized clinical trial evidence on the scale needed to answer questions about nonskeletal benets of vitamin D, says Bess Dawson-Hughes, MD, director of Tufts HNRCA Bone Metabolism Laboratory.

nnounced in October, the D2d study based at Tufts Medical Center will test vitamin D supplementation in adults with prediabetes. Anastassios G. Pittas, MD, the studys principal investigator, explains, Past observational studies have suggested that higher levels of vitamin D may be beneficial in preventing type 2 diabetes, but until this large, randomized and controlled clinical trial is complete, we wont know if taking vitamin D supplements lowers the risk of diabetes. Based on observations from earlier studies, researchers speculate that vitamin D could reduce the diabetes risk by 25%. The study will also examine if sex, age or race affect the potential of vitamin D to reduce progression to diabetes. The $40 million study will take place at 20 medical centers in 17 different states across the country. For more information about D2d, including how to participate, see <www.d2dstudy.org>.

ANSWERS AHEAD: Tufts Dr. Dawson-

SEEING BUT NOT PROVING: In the new review, Philippe Autier, MD, of the International Prevention Research Institute in France, and colleagues found that low blood levels of vitamin D were associated with greater risk of all-cause mortality as well as cardiovascular disease, inammation, glucose metabolism disorders, infectious diseases, mood disorders and cognitive decline. Participants in observational studies with sucient vitamin
6

Hughes adds, To answer these questions is why the National Institutes of Health (NIH) has funded the large VITAL study at Harvard and the D2d trial in prediabetics being done here at Tufts, among others. The VITamin D and OmegA-3 TriaL (VITAL), involving 20,000 men and women across the US, will test whether taking daily supplements of vitamin D3 (2,000 IU) or omega-3 fatty acids (1 gram) reduces the risk for developing cancer, heart disease and stroke in

people who do not have a prior history of these illnesses. The multiyear Vitamin D and Type 2 Diabetes (D2d) study, based at Tufts Medical Center (see box), will include about 2,500 people. It will investigate whether daily supplements of 4,000 IU of vitamin D3 will prevent or delay type 2 diabetes in adults aged 30 or older with prediabetes. Until these studies begin to produce more denitive answers, several years from now, the best advice is to follow the Institute of Medicine recommendation of 600 IU of vitamin D daily for people under age 70, 800 IU for ages 70-plus. People at risk of osteoporosis and those who live in northern latitudes with inadequate sunshine to make vitamin D in the skin may want to take a supplement to help protect their bones. After a careful review, the Institute of Medicine found no evidence of danger from vitamin D intake up to 4,000 IU per day, Dr. Dawson-Hughes says. You wont be hurting yourself. Whether you will help yourself beyond bone health, however, is a question scientists are working hard to answer.

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Rx for Combating Chronic Conditions: Exercise

TAKE CHARGE!

A
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Surprising study nds benets of exercise as great as those of medication.

Nonetheless, the pool of prior research was enough for Naci and Dr. Ioannidis to develop an elaborate crosscomparison of outcomes for drugs, exercise or, more rarely, both. Most of the exercise studies involved rehabilitation programs; walking or other aerobic exercises were most commonly studied, but some trials looked at weight training or other routines. The available studies tracked mortality among patients with heart disease, diabetes, stroke or chronic heart failure. Overall, the results were almost identical for patients assigned to medications and those who exercised. As the researchers put it, All interventions were not dierent beyond chance. When analyzed by specic diseases, patients with heart disease and diabetes had the same relative risk of dying whether they exercised or took medications. Those who had suered a stroke actually did better if they exercised, compared to drug treatmentpossibly because stroke patients who exercised

potentially life-saving prescription for ghting heart disease, diabetes and stroke could be as close as those walking shoes gathering dust in your closet. According to an unusual new study, the benets of exercise in reducing mortality from those leading causes of death match or even exceed the eects of prescription drugs for the same conditions. Patients with heart disease who exercised, for instance, had the same odds of surviving the condition as those given medications such as statins or antiplatelet drugs. This doesnt mean you should stop taking your medications, comments Miriam E. Nelson, PhD, a professor in Tufts Friedman School and author of the Strong Women series of books. But it does suggest how eective exercise can be whether or not it is added to whatever drug regimen your physician prescribes.

f youre walking for health, does it matter how fast you go? Contrary to some previous findings, a new analysis of data on almost 39,000 participants in the National Walkers Health Study reports that a brisk pace has more benefitseven if the distance traveled is the same. Looking at 2,000 deaths among walkers, researchers found mortality disproportionately higher among those with the slowest pace (17 minutes or more per mile, with most taking at least 20 minutes and many even longer). The death rate for the slowest walkers remained higher even if they walked as far per day as faster walkers. Overall, the risk was especially higher for those dawdling along at 24 minutes a mile or slower. Picking up your pace even a little seemed to pay off, however: Those classified in the third-slowest category of walkers (about 15-17 minutes per mile) saw a significant reduction in their risk of dying prematurely compared to the slowest group.

were healthier to begin with. Only patients with chronic heart failure did not live at least as long in experiments where they exercised compared to those where they were assigned to drugs such as diuretics.

ADDING EXERCISE: Our results suggest

MOVING VS. MEDS: In the new study,

published in the journal BMJ, So Huseyin Naci, a graduate student at the London School of Economics and Political Science, and John Ioannidis, MD, DSc, director of the Stanford Prevention Research Center, looked at 305 previous experiments totaling almost 305,000 participants. All were randomized clinical trials, considered the gold standard of scientic research. Most, however, focused on medications, with only 57 involving almost 15,000 volunteers testing the benets of exercisereecting, researchers said, how we need far more information on the eectiveness of exercise against chronic conditions.

ARE YOU DOING ENOUGH?

ow much exercise do you need? Current guidelines for older adults call for 150 minutes per week of moderateintensity aerobic activity, such as brisk walking, or 75 minutes a week of vigorous aerobic activity, such as jogging. Or you can aim for an equivalent mix of moderate and vigorous activity. Plus you should do muscle-strengthening activities on two or more days a week that work all major muscle groups.

that exercise can be quite potent in treating such conditions, Dr. Ioannidis said. Co-author Naci added, Maybe people could think long and hard about their lifestyles and talk to their doctors about incorporating exercise into their care along with prescription drugs. Tufts Nelson agrees, advising, You may never have exercised regularly before, or it may be a long time since you did. For that reason, the key to long-term success is to take it slowly but deliberately, increasing the duration and intensity of your exercise a little bit at a time. That will allow you to gain the greatest benet without burning out. And for aerobic exercise, in particular, choose exercises that you enjoy. Thats also crucial for sticking with it.
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MARCH 2014

ASK TUFTS EXPERTS Yerba mat tea Artificial sweeteners and diabetes Alcohol and bones

Irwin H. Rosenberg, MD

Health & Nutrition Letter Editor Professor of Nutrition, Friedman School of Nutrition Science and Policy Tufts University

Q A

Are there actually health benefits from drinking yerba mat tea? What is yerba mat, anyway?

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Diane L. McKay, PhD, an assistant professor at Tufts Friedman School, replies: Yerba mat tea is made with the dried leaves of Ilex paraguariensis, a subtropical evergreen tree native to South America. Fresh mat leaves undergo several stages of processing including blanching, drying and aging prior to packaging. During blanching, the mat leaves are flash-heated over an open flame. The leaves are then dried very slowly, often using wood smoke, and aged for up to 12 months for flavor development. The name mat is derived from the Quechua word mat meaning a cup or vessel used for drinking. Other names for beverages made with I. paraguariensis include Jesuits tea, Paraguayan tea, cimarrn and chimarra. In the United States, mat is commercially packed in individual tea bags or as a tea concentrate. Mat has long been used by the indigenous peoples of South America, especially the Guarani Indians. In folk medicine, mat is used as a central nervous system stimulant, diuretic and anti-rheumatic. The German Commission E (a scientific advisory board to the equivalent of the FDA) approved the internal use of mat for mental and physical fatigue. Although in vitro and animal studies suggest a potential anti-carcinogenic effect of mat, the available epidemiological evidence does not. Several case control studies conducted in South America reported an association between the consumption of yerba mat tea and an increased risk of oral, laryngeal, esophageal, lung, kidney and bladder cancers. These negative effects may be due to the way the tea leaves are processed in South America. That is, during the drying process there is some introduction of carcinogens from the smoke used; the carcinogens are called polycyclic aromatic hydrocarbons. Few clinical trials of mat have been published, and none have reported any statistically significant findings that can be attributed to mat consumption. Bottom line, yerba mat is an effective pickme-up (due to the presence of naturally occurring stimulants), but the jury is still out on whether any of the potential benefits suggested by cell culture or animal studies will pan out in humans.

My physician tells me that I am pre-diabetic, so I am very careful about my sugar and carbohydrate intake. Do artificial sweeteners raise bloodsugar levels?

Anastassios G. Pittas, MD, professor of medicine in the Division of Endocrinology, Diabetes & Metabolism at Tufts Medical Center, responds: The quick answer is that artificial sweeteners do not raise blood sugar levels since they have no caloric value. However, switching to artificially sweetened food and/or beverages to prevent diabetes may not have the desired result, which may be counterintuitive. Artificial sweeteners may mess with the areas of the brain that control appetite and satiety and, when used long-term, MAY have the opposite effects than desired.

Ive read conflicting reports on the effects of alcohol on bones. Assuming one is drinking in moderation, is alcohol good or bad for bones?

Katherine L. Tucker, PhD, a professor at the University of Massachusetts-Lowell and adjunct professor at Tufts Friedman School, answers: It has long been thought that alcohol is bad for bones, and it is clear that very heavy alcohol consumers have higher risk of osteoporosis. However, the evidence does not support that for moderate consumers. Most studies show that moderate alcohol consumers have higher bone mineral density (BMD) than non-consumers, but that there is an inverse U-shaped curve, with lower BMD for high consumers. A 2009 Tufts study by Tucker and colleagues, for example, concluded, The positive relation between intake of alcohol and BMD in men and postmenopausal women, the reproducibility of these effects across the different bone sites, and the consistency of these findings with other published studies of total alcohol intake suggest that alcohol intake, particularly from beer and wine, may protect bone health. However, intake of more than two drinks per day of liquor in men was clearly harmful. These apparent beneficial effects, Tucker adds, are thought to be related to the estrogenic effects of alcohol itself, polyphenolics in wine or beer, and silicon in beer.

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