Monday, February 28, 2011

The Importance of 'Don't' in Inducing Ethical Employee Behavior

Research & Ideas : Harvard Business School

Published: February 28, 2011
Author: Carmen Nobel

Executive Summary:

In a new study, HBS professors Francesca Gino and Joshua D. Margolis look at two ways that companies can encourage ethical behavior: the promotion of good deeds or the prevention of bad deeds. It turns out that employees tend to act more ethically when focused on what not to do. That can be problematic in firms where success is commonly framed in terms of advancement of positive outcomes rather than prevention of bad ones. Key concepts include:

* In general, there are two ways a company can encourage ethical conduct among its employees: either the promotion of good actions and outcomes or the prevention of bad ones.
* Through several experiments, the professors found that inducing a prevention focus will lead to ethical behavior more than inducing a promotion focus.
* In encouraging ethical behavior among employees, it behooves firms to consider focusing on preventing negative outcomes, not only in creating a code of ethics but also in setting goals and framing task directives.

In trying to encourage good moral conduct, it's common for a company to come up with a list of don'ts—wording policies such that they focus on unethical behavior employees should avoid rather than on ethical acts they should strive to achieve. Don't cheat. Don't lie. It's a tendency that dates back to the Ten Commandments, the vast majority (eight) of which dictate what thou shalt not do.

Meanwhile, in virtually every other aspect of business there is a focus on what to do. Do meet sales projections. Do outperform competitors. Do impress the boss by getting things done.

"The default tendency is for companies to frame goals in terms of promotion, and what we show here is that this might actually lead to cheating as a side effect."

The dichotomy raises an important question: If employees are generally focused on the benefits of getting things done, will they be attentive to messages about what not to do? Harvard Business School professor Joshua D. Margolis draws a parallel to stage directions in a high-school play. "If you're always told when to enter, you might skip over the one time you're told to exit," he says.

Margolis and fellow HBS professor Francesca Gino explore the issue in a new research paper, "Bringing Ethics into Focus: How Regulatory Focus and Risk Preferences Influence (Un)ethical Behavior," in which they distinguish between two ways a company can encourage ethical conduct among its employees: either the promotion of being ethical or the prevention of being unethical. (The paper will be published in the academic journal, "Organizational Behavior and Human Decision Processes.")

"Since the Enron scandal, there has been a lot of research across disciplines on why even good people do wrong," Margolis says. "But we have relatively little research to date that says, so, what do you do about it? That's the big game that we're hunting. What are some simple implementations or changes managers can introduce in their organizations to encourage good behavior?"
Promotion or prevention?

Through a series of experiments with college and graduate students, which are detailed in the paper, Gino and Margolis set out to induce individuals to focus on either promotion or prevention via a series of situational cues. They then studied whether the subconscious adoption of either a promotion or a prevention focus could affect an individual's behavior.

The researchers now contend that a person's focus, either promotion or prevention, can indeed influence his or her ethical behavior at any given time.

"I think the main message of the paper is that with situational cues, you can trigger one type of motivation versus the other," Gino says. "And because of this motivation, people end up cheating more or less. What we find is that the cues that induce a promotion focus—this idea of attaining high levels of performance—can lead to more cheating than prevention-focus types of framework or cues."

In one experiment, students had to come up with anagrams under the time pressure of 90 seconds per round, over a series of six rounds, with the understanding that they would be scoring themselves at the end of the test—and that they would be rewarded for high performance.

"In each round, participants were given a series of seven letters and asked to create as many words as possible," the paper explains. "The last series of letters was presented in a different order for each participant so that we could track who cheated and to what extent by comparing workbooks and answer sheets with participants' self-reported performance."

The students learned that they would each receive a Scrabble dictionary to check their work, after which they would fill out an answer sheet to report their performance. But before providing the dictionaries, the researchers distributed a pencil-and-paper maze to each student, in which the goal was to help a trapped cartoon mouse find its way out.

In some mazes, a picture of a piece of cheese sat outside the exit, next to a hole in the wall where the mouse could escape. This was meant to induce a promotion focus: Go get that reward! In other cases, in lieu of cheese, there was a menacing cartoon owl hovering above the maze, such that it behooved the mouse to reach the exit so as not to become bird food. That maze was meant to induce a prevention focus: Don't get killed!

Once they had completed the mazes, the students returned to the task of scoring themselves on the anagram test. They were told to pay themselves from the envelope on their desks according to their performance.

The results showed that the students who completed the cheese maze were far more likely to overstate their results, and to reward themselves accordingly, than those who completed the maze with the scary owl—82 percent (37 out of 45 participants) and 39 percent (16 out of 41 participants), respectively.

In a separate experiment, the researchers demonstrated that they could induce a promotion or prevention focus simply by phrasing the goals of the study in two different ways. Some students received promotion-based instructions that included the following statement, focusing on advancement: "This research project is being conducted to advance the ideals and aspirations pursued by applied social science." Others received a statement focusing on compliance: "Statement of Research Code of Conduct—This research project is being conducted with strict adherence to the standards and obligations required of applied social science."

Again, the students who were steered toward a promotion focus were more likely to cheat on the activities that followed. In other words, inducing a prevention focus may lead to more ethical behavior than inducing a promotion focus. Company executives may want to take note.

"The default tendency is for companies to frame goals in terms of promotion, and what we show here is that this might actually lead to cheating as a side effect," Gino says. "So the idea is to maybe revise those policies in terms of prevention so that they could trigger [ethical behavior]."

In yet another experiment, the researchers repeated the anagram tests, the mazes, and the monetary rewards with a different set of students, but then they added a wrinkle: After rewarding themselves from the envelopes on their desks, the students had the opportunity to donate some of their winnings to National Public Radio.
Tracking moral and immoral actions

The results showed that a much larger number of the student participants donated money to NPR in the promotion focus (10 out of 33) than in the prevention focus (2 out of 33). In other words, while inducing a promotion focus seemed to induce unethical acts, it also led to higher levels of virtuous behaviors to make up for those unethical acts.

"So there is evidence for the fact that people like to feel that they're in balance when it comes to ethics," Gino says. "People are guided by their moral compass when facing ethical dilemmas. And they keep track of their moral and immoral actions. There's a sense that there's a moral scale inside of you, and you want to keep it balanced."

Eventually, Gino and Margolis plan to work within several companies to discover particular ways to incorporate a prevention focus into their bottom line, while still encouraging financial success. In the meantime, managers can be mindful of striking a balance between morals and money when setting goals and offering rewards.

"When you're a manager helping to set up the conditions in which people operate, be attuned to the messages you're sending," Margolis says. "If the message is, 'Be sure not to step over the line, but hit those numbers,' don't be shocked if people forget the first message. You need to be clear about penalties even as you are clear about goal setting. You want a healthy setting between those."
About the author

Carmen Nobel is a senior editor at HBS Working Knowledge.

Analysis Suggests Back Disease May Run in Families

From Medscape Medical News

Norra MacReady

February 4, 2011 — In an analysis of a database of more than 2 million people, first-degree and third-degree relatives of people with lumbar disc disease had a significantly increased relative risk of developing the back condition themselves compared with expected rates for the general population. "The results of this study support a heritable predisposition to lumbar disc disease," lead author Alpesh A. Patel, MD, and colleagues from the departments of Orthopaedics and Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, report in the February 2 issue of the Journal of Bone and Joint Surgery.

Low back pain is common and costly — its estimated lifetime risk in the United States is 84%, with an annual cost that exceeds $100 billion — yet its etiology remains incompletely understood, the authors write. Several earlier studies have hinted at a familial predisposition, but "we are aware of no study that has evaluated the familial clustering of lumbar disc disease on a population-based, multigenerational level."

To test the hypothesis that lumbar disc disease may be inherited, the authors analyzed data from both the Utah Population Database, which permits the tracking of medical information on the founding pioneers of Utah and their descendents, and the University of Utah Health Sciences Center data warehouse, which has diagnosis and procedure data on all patients treated at the University Hospital. Together, the databases contain information on more than 2.4 million patients. Only patients and control participants with at least 3 generations of genealogical data were included in the study.

Of those individuals, 1254 people had at least 1 diagnosis of lumbar disc disease or lumbar disc herniation, along with the requisite genealogical data. The authors tested for heritability in 2 ways: by estimating the relative risk for lumbar disease in relatives and by determining a genealogical index of familiality (GIF). They compared their findings in affected families with the expected results for the general population of Utah.

First-degree relatives of people with lumbar disc disease had a relative risk of 4.15 of having the disease themselves (95% confidence interval [CI], 2.82 - 6.10; P < .001). In third-degree relatives, the relative risk was 1.46 (95% CI, 1.06 - 2.01; P = .027). Relative risk was slightly elevated in second-degree relatives, at 1.15, but this was not significant (95% CI, .71 - 1.87; P = .60), perhaps because of limitations in the data.

The GIF tests the hypothesis that there is no excess familial clustering, or relatedness, of the phenotype of interest by measuring excess relationships between pairs of patients compared with pairs of control participants. "It is not the absolute value of the GIF statistic that reveals excess relatedness of disease, but the relative value of the case-GIF to the control-GIF," the authors explain. In this analysis, the case overall GIF was 3.05 compared with a mean control GIF of 2.51 (P < .001 for overall GIF), suggesting "a significant excess of relationships among patients compared with controls."

The investigators relied on International Classification of Diseases, Ninth Revision, codes to identify patients, so diagnostic accuracy may have varied, depending on physician specialty and experience, they noted. Also, they were unable to determine disease severity and response to treatment. Genetically, the population of Utah is similar to the US population and to the northern European population from which the founders of Utah came, so the findings may be generalized to those groups.

Now that a genetic predisposition to lumbar disc disease has been identified, the authors conclude, "identification of the specific genetic products responsible for lumbar disc disease may help in the development of potential biologic interventions to prevent and/or treat lumbar disc disease in the population at large."

In an accompanying editorial published online, David A. Wong, MD, from the Denver Spine Center, Greenwood Village, Colorado, commends Dr. Patel and colleagues for their study design and conclusion. Dr. Wong remarks on the future possibilities that may lead researchers to identify specific genes responsible for spine and other musculoskeletal disorders, akin to what is currently known about breast cancer. He states: "We can look forward to more genetic research in the area of the spine. Inevitably better treatments are likely to be found. Perhaps the treatment for so-called black disc disease is lurking on the horizon."

One or more of the authors received outside support or grants in excess of $10,000 from the National Institutes of Health-National Library of Medicine to support the research or preparation for this study. No other relevant financial disclosures were made.

J Bone Joint Surg Am. 2011;93:225-229. Abstract

Tuesday, February 15, 2011

Updated USDA Dietary Guidelines Released C

From Medscape Education Clinical Briefs

News Author: Emma Hitt, PhD
CME Author: Laurie Barclay, MD

Clinical Context

Achieving and maintaining a healthy weight require eating and physical activity patterns focused on consuming fewer calories, making informed food choices, and increasing participation in physical exercise. Benefits of such a program also include lower a risk for chronic disease and improvements in overall health.

The Dietary Guidelines for Americans, 2010 discusses these strategies and issues recommendations for Americans 2 years and older, including those at increased risk for chronic disease.
The guidelines are tailored to the food preferences, cultural traditions, and customs of the many and diverse groups residing in the United States and also offer specific recommendations for groups based on age, sex, and special considerations such as pregnancy.

Study Highlights

* Overweight and obesity can be prevented and/or reduced through improved eating and physical activity behaviors.
* Body weight can be managed by controlling total calorie intake.
* For overweight or obese individuals, management of body weight requires consuming fewer calories from foods and beverages.
* Physical activity should be increased, and time spent in sedentary activities should be reduced.
* Appropriate caloric balance needs to be maintained during each life stage, including childhood, adolescence, adulthood, pregnancy and breast-feeding, and older age.
* Daily sodium intake should be reduced to less than 2300 mg in the general population and to less than 1500 mg for those 51 years and older; African Americans; or individuals with hypertension, diabetes, or chronic kidney disease.
* Less than 10% of calories should come from saturated fatty acids; these should be replaced with monounsaturated and polyunsaturated fatty acids.
* Dietary cholesterol intake should not exceed 300 mg per day.
* Trans-fatty acid intake should be minimized by limiting foods containing partially hydrogenated oils and other solid fats.
* Calorie intake should be reduced from solid fats, added sugars, and foods containing refined grains, especially those containing solid fats, added sugars, and sodium.
* If alcohol is consumed, it should be limited to 1 drink per day or less for women and 2 drinks per day or less for men, and only by adults of legal drinking age.
* Within daily caloric needs, vegetable and fruit intake should be increased, especially dark-green, red, and orange vegetables; beans; and peas.
* At least half of all grains consumed should be whole grains, and refined grains should be replaced with whole grains whenever possible.
* Intake of fat-free or low-fat milk and milk products (eg, milk, yogurt, cheese, or fortified soy beverages) should be increased.
* Protein foods should include a variety of sources (eg, seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds), with seafood replacing some meat and poultry when feasible.
* Protein foods higher in solid fats should be replaced with those that are lower in solid fats and calories and/or are sources of oils.
* Oils should replace solid fats when possible.
* Because American diets may be lacking in potassium, dietary fiber, calcium, and vitamin D, dietary sources of these should be increased by eating proportionately more vegetables, fruits, whole grains, and milk and milk products.
* Women of childbearing potential should favor foods supplying heme iron and vitamin C-rich foods to enhance iron absorption.
* In addition, they should consider additional iron sources and consume 400 μg per day of synthetic folic acid from fortified foods and/or supplements as well as foods rich in folate.
* Women who are pregnant or breast-feeding should consume 8 to 12 ounces seafood per week from a variety of seafood types, excluding tilefish, shark, swordfish, and king mackerel because of their high content of methyl mercury.
* Similarly, white (albacore) tuna intake should not exceed 6 ounces per week.
* Pregnant women should take an iron supplement recommended by their physician.
* Persons 50 years and older should consume vitamin B12-fortified foods (eg, fortified cereals) or dietary supplements.

Clinical Implications

* To achieve and sustain a healthy weight, the USDA and the US Department of Health and Human Services guidelines stress the importance of maintaining calorie balance with time by consuming only enough calories from foods and beverages to meet their needs and by being physically active.
* The USDA and the US Department of Health and Human Services guidelines also emphasize the need to consume nutrient-dense foods and beverages, while avoiding calorie-dense foods and beverages low in nutritional value.

Alcohol Kills More Than AIDS, TB or Violence-WHO

From Reuters Health Information

By Stephanie Nebehay

GENEVA (Reuters Health) Feb 11 - Alcohol causes nearly 4% of deaths worldwide, more than AIDS, tuberculosis or violence, the World Health Organization warned on Friday.

Rising incomes have triggered more drinking in heavily populated countries in Africa and Asia, including India and South Africa, and binge drinking is a problem in many developed countries, the United Nations agency said.

Yet alcohol control policies are weak and remain a low priority for most governments despite drinking's heavy toll on society from road accidents, violence, disease, child neglect and job absenteeism, it said.

Approximately 2.5 million people die each year from alcohol related causes, the WHO said in its "Global Status Report on Alcohol and Health."

"The harmful use of alcohol is especially fatal for younger age groups and alcohol is the world's leading risk factor for death among males aged 15-59," the report found.

In Russia and the Commonwealth of Independent States (CIS), every fifth death is due to harmful drinking, the highest rate.

Binge drinking is now prevalent in Brazil, Kazakhstan, Mexico, Russia, South Africa and Ukraine, and rising elsewhere, according to the WHO.

"Worldwide, about 11% of drinkers have weekly heavy episodic drinking occasions, with men outnumbering women by four to one. Men consistently engage in hazardous drinking at much higher levels than women in all regions," the report said.

Health ministers from the WHO's 193 member states agreed last May to try to curb binge drinking and other growing forms of excessive alcohol use through higher taxes on alcoholic drinks and tighter marketing restrictions.


Alcohol is a causal factor in 60 types of diseases and injuries, according to WHO's first report on alcohol since 2004.

"Six or seven years ago we didn't have strong evidence of a causal relationship between drinking and breast cancer. Now we do," Dr. Vladimir Poznyak, head of WHO's substance abuse unit who coordinated the report, told Reuters Health.

Alcohol consumption rates vary greatly, from high levels in developed countries, to the lowest in North Africa, sub-Saharan Africa, and southern Asia, whose large Muslim populations often abstain from drinking.

Homemade or illegally produced alcohol -- falling outside governmental controls and tax nets -- accounts for nearly 30% of total worldwide adult consumption.

In France and other European countries with high levels of adult consumption, heavy episodic drinking is rather low, suggesting more regular but moderate drinking patterns.

One of the most effective ways to curb drinking, especially among young people, is to raise taxes, the report said. Setting age limits for buying and consuming alcohol, and regulating alcohol levels in drivers, also reduce abuse if enforced.

Some countries restrict marketing of alcoholic beverages or on the industry's sponsorship of sporting events.

"Yet not enough countries use these and other effective policy options to prevent death, disease and injury attributable to alcohol consumption," the WHO said.

Alcohol producers have said they recognize the importance of industry self-regulation to address alcohol abuse and promote curbs on drunk drinking and illegal underage drinking.

But the brewer SABMiller has warned that policy measures like minimum pricing and high excise taxes on alcohol could cause more public health harm than good by leading more people to drink homemade or illegally produced alcohol.

Wednesday, February 9, 2011

Late Meals Associated With Obesity Risk

From Medscape Medical News

Norra MacReady

October 25, 2010 (San Diego, California) — A preference for late dinners might increase your risk for obesity, according to a small study presented here at Obesity 2010: The Obesity Society 28th Annual Scientific Meeting.

Rika Yokoyama, MS, and colleagues from the Health Care Food Research Laboratories of the Kao Corporation in Tokyo, Japan, compared the effects of early and late meals in a crossover study of 10 healthy Japanese men. The men consumed lunch at 1:00 pm and breakfast the following day at 8:00 am; they had dinner at 7:00 pm in the early dinner (ED) condition and at 10:00 pm in the late dinner (LD) condition. All meals were the same, and were consumed in a respiratory chamber, where the subjects' energy expenditure and fuel utilization were measured from 12:30 pm until 11:30 am the next day.

Blood metabolite levels were measured 1 hour after every meal, and the men rated their appetite hourly on a visual analogue scale (VAS), which ranged from 0 (not hungry at all) to 100 (as hungry as I've ever felt). The men had an average age of 40.4 (±6.9) years and an average body mass index of 23.1 (±2.2) kg/m2.

In the ED condition, average 23-hour energy expenditure was 1885 (±231) calories; in the LD condition it was 1837 (±228) calories (P < .05).

"We saw a sharp decline in postprandial energy expenditure, or diet-induced thermogenesis (DIT), during sleep after the LD condition. In the ED condition, the decline was more moderate," Ms. Yokoyama told Medscape Medical News. "Presumably, that was because in the ED condition, more time elapsed between dinner and bedtime. However, we could not identify the reason the DIT declined so sharply during sleep after the late dinner." Nor could the differences be traced to variations in physical activity; infrared motion sensors in the respiratory chamber did not detect any changes in physical activity between the conditions," she explained.

Insulin and blood glucose levels were markedly higher in the LD than in the ED condition after dinner (P < .01). Free fatty acids were also higher in the LD condition, and remained elevated until breakfast the following day. The authors concluded that eating dinner late was associated with lower total energy expenditure, hyperinsulinemia, and hyperglycemia, which over time could result in obesity.

Appetite scores on the VAS also were significantly higher just before dinner in the LD than in the ED condition (P < .05).

"This small study is provocative and may serve to suggest hypotheses that could and should be tested in larger studies before generalizable conclusions can be drawn," said Howard Eisenson, MD, associate professor of community and family medicine, and executive director of the Duke Diet and Fitness Center at Duke University School of Medicine in Durham, North Carolina.

Still, he said, "I believe that those specializing in the treatment of obesity will not be surprised that, at least in this small and very short-term study, a late night dinner seems to be associated with unfavorable changes in terms of weight management and risk for diabetes: increased appetite, decreased energy expenditure, and increased insulin and blood sugar levels. The implications for clinical practice are not yet clear, but this preliminary study should trigger broader research and may ultimately provide good evidence to support a personal and public health message."

Ms. Yokoyama and Dr. Eisenson have disclosed no relevant financial relationships.

Obesity 2010: The Obesity Society 28th Annual Scientific Meeting. Poster 202-P. Presented October 12, 2010.

Tuesday, February 8, 2011

Sun Exposure, Vitamin D Independently Linked to Lower MS Risk

From Medscape Medical News > Neurology

Pauline Anderson

February 7, 2011 — A new study appears to cement the suspected link between sun exposure and lower rates of multiple sclerosis (MS).

The Australian case-control study found that past and current sun exposure and serum vitamin D levels are independently associated with a reduced risk for a central nervous system (CNS) first demyelinating event (FDE). The association remained after adjusting for potential confounders and did not vary by study region, sex, or type of demyelination.

The study is unique in several ways, said one of the study authors, Anne-Louise Ponsonby, PhD, professor at the Murdoch Children's Research Institute in Melbourne, Australia. For example, it included more than 1 site, enrolled people with a demyelinating event who had not yet been diagnosed as having MS, and investigated both sun and vitamin D levels simultaneously.

"The study raises the question of whether sun exposure itself is important, separate from vitamin D," said Dr. Ponsonby. She acknowledged that although the sun is believed to have direct immune effects in addition to providing vitamin D, the sun exposure effect found in the study could simply reflect longer-term vitamin D status. "In any case, it's important to study both vitamin D and sun exposure to understand the effects on immune function and MS."

The Autoimmune Study is published in the February 8 issue of Neurology.

Varying Latitudes

The study included 282 patients from 4 regions of Australia with varying latitudes (Brisbane City, Newcastle, Geelong City and Western Districts of Victoria, and the island of Tansmania) who had a first clinical diagnosis of CNS demyelination within the study period. Of these, 16 had a distinct event during the study period, whereas others may have had a previous event. The study also included 542 controls randomly selected from the Australian Electoral Roll, 395 of whom were matched to an eligible FDE case.

Inclusion of subjects with an FDE rather than established MS minimized changes in behavior, said Dr. Ponsonby. "It means it was before they introduced any disease-related changes to their lifestyle." About 60% of people presenting with a demyelinating event will progress to MS within 10 years, she said.

The multisite nature of the study allowed the researchers to compare various latitudes. "We designed the study so we could not only look at sun exposure and vitamin D but also see how much of that was accounted for by latitude gradient," said Dr. Ponsonby.

Through questionnaires, researchers collected information on sun exposure during leisure time (weekends and holidays) in summer and winter for different periods of life (6-10 years, 11-15 years, 16-20 years, and last 3 years). With this information, the researchers were able to examine past sun exposure before the onset of MS.

Determining sun exposure before the age of 6 years would have been too problematic, said Dr. Ponsonby. "At least by the age of 6 or 10 years, people have anchoring events like going to primary school, so they might have some recall of their sun exposure."

Researchers also gathered data on subjects' propensity to tan or burn, their number of freckles as a teenager, smoking history, educational level, physical activity, diet, and use of vitamin D supplements. As well, they noted each patient's eye and skin color and grades of actinic skin damage and collected blood samples for DNA and vitamin D analysis.

Accumulated Sun Exposure

The study showed that both sun exposure and current vitamin D levels contributed independently to reduced FDE risk. Accumulated leisure time sun exposure, defined as the dose per 1000 kJ/m2 at the age of 6 years to present, had an adjusted odds ratio (AOR) of 0.70 (95% confidence interval [CI], 0.53 – 0.94) for each UV dose increment of 1000 kJ/m2.

For vitamin D, the AOR for decreased FDE risk was 0.93 (95% CI, 0.86 – 1.00) per 10-nmol/L increase in serum 25-hydroxyvitamin D (25[OH]D) levels.

As well, fair skin and a higher nevus count were associated with increased FDE risk. The AOR for actinic skin damage score (>3 grade vs ≤3) was 0.42 (95% CI, 0.26 – 0.70).

The study authors determined that the differences in leisure time sun exposure, serum 25(OH)D levels, and skin type additively accounted for a 32.4% increase in FDE incidence from the low to high latitude regions.

"We've got fewer FDE cases in Queensland and more in Tasmania, and for a long time, people said that this might reflect sun exposure," said Dr. Ponsonby. "We found in this study that yes, indeed, sun exposure and low vitamin D did explain the gradient but only part of it, only a third of it."

The results were similar for the larger group, who may have had a previous demyelinating event, and the smaller, "purer" group, whose first event definitely occurred during the study period, said Dr. Ponsonby. "This helps to indicate that there wasn't any history of disease problems causing them to change their sun exposure or vitamin D."

Risk Persisted After Adjustments

The FDE risk persisted after adjusting for factors thought to be associated with MS, including freckles, exercise, diet, smoking, and eye color. "Particularly important was adjusting for skin type," said Dr. Ponsonby, who pointed out that whites are more prone to sun damage and tend to have higher risk for MS.

"We thought it was important to make sure that low vitamin D and sun exposure weren't just a marker for any of those other things," she said. "These other factors didn't explain in any way the pattern between low sun exposure and vitamin D."

Also implicated in MS is genetic predisposition, a history of infectious mononucleosis, and Epson-Barr virus infection, she added.

The findings suggest that vitamin D supplements alone may be a less effective prevention intervention than has been implied in previous epidemiology studies, said the study authors.

How might UV and vitamin D affect MS rates? According to the study authors, both independently stimulate T-regulatory cells and secretion of interleukin 10, reduce levels of the proinflammatory cytokine interleukin 17, and dampen TH1 immune function. This, they said, provides "biological plausible pathways to reduced MS risk."

The researchers were only able to adjust for 1 of the 3 genes recently identified in a genome-wide association study as determining serum 25(OH)D levels. However, the combined effect of these genetic variants was apparently not large because only 1% to 4% of the variation in serum 25(OH)D was attributed to their combined effect, they write.

Growing Evidence

Approached for a comment on these findings, Lily Jung Henson, MD, medical director of Neurology Clinic, Swedish Medical Group, Seattle, Washington, said there's nothing really new or different about this study.

"It just adds to the growing evidence we have that vitamin D deficiency, potentially associated with lack of sun exposure, can contribute to MS," she said.

R. M. Lucas, PhD, receives research support from Multiple Sclerosis Research Australia, The Royal Australasian College of Physicians, and the National Health and Medical Research Council of Australia. Dr. Ponsonby receives research support from Multiple Sclerosis Research Australia and the National Health and Medical Research Council of Australia. For further disclosures, see original article.

Neurology. 2011;76:540-548.

Friday, February 4, 2011

Annual Mammograms Beginning at Age 40 Save More Lives

From Medscape Medical News > Oncology

Roxanne Nelson

February 3, 2011 — A new analysis is poised to reignite the debate that has been raging over the value of mammography in women younger than 50 years of age.

There was a furor when the revised US Preventative Service Task Force (USPSTF) recommendations for breast cancer screening were released in November 2009. The most notable changes were to advise against routine screening mammograms for women 40 to 49 years of age, to change the screening interval from 1 to 2 years in women 50 years and older, and to end screening at 74 years.

The updated guidelines became mired in controversy as soon as they were published, as previously reported by Medscape Medical News. A number of organizations, including the American Cancer Society (ACS), the American College of Radiology, and the American College of Obstetricians and Gynecologists, recommended that physicians and patients continue to follow earlier guidelines.
Dr. Edward Hendrick

Now, a study published in the February issue of the American Journal of Radiology that analyzed the same data as the USPSTF has come up with very different results.

R. Edward Hendrick, PhD, clinical professor of radiology at the University of Colorado School of Medicine in Denver, and Mark Helvie, MD, director of breast imaging at the University of Michigan Comprehensive Cancer Center in Ann Arbor, found that beginning screening at a younger age and at more frequent intervals can save more lives.

"What is most important is to save the most lives," Dr. Hendrick told Medscape Medical News, "not to do the fewest mammograms. If you want to save the most lives, then doing annual mammograms from age 40 to 84 years clearly is superior."

According to the analysis, women who receive annual mammograms starting at age 40 can significantly reduce the risk of dying from breast cancer by 71%.
This is in contrast to women who follow the USPSTF recommendations, who had a 23.2% reduction in mortality.

Lower Mortality With Earlier Screening

Dr. Hendrick and Dr. Helvie used 6 model scenarios of screening mammography that were created by the Cancer Intervention and Surveillance Modeling Network, which is the same modeling data used by the USPSTF. They compared mortality reduction for women who followed the 2009 USPSTF recommendations with that for women who followed the ACS recommendations (annual screening beginning at age 40).

"In their summary paper, the USPSTF did not do any averaging over the 6 models," explained Dr. Hendrick. In our analyses, we selected a model that was "somewhere in the middle, but it wasn't an average over the 6."

When the USPSTF looked at any of these modeling data, they chose the point on the graph when it first begins to turn over in terms of mortality reduction per mammogram done. "That was biennial screening beginning at age 50," he said.

In contrast, the authors of new analysis averaged the 6 models and found that for women 40 to 84 years, annual screening conveyed an estimated 39.6% reduction in mortality (range over the 6 models, 29.4% to 54%). This was compared with biennial screening at 50 to 74 years, which showed an estimated mortality reduction of 23.2% (range, 20% to 28%).

They found that approximately 12 lives per 1000 women screened would be saved with annual screening beginning at age 40, whereas with the USPSTF-recommended screening regimen, an estimated 7 lives per 1000 women screened would be saved. Overall, the ACS screening guidelines would result in 5 more lives per 1000 women saved than the USPSTF screening guidelines.

Overemphasis of Harms

The USPSTF also overemphasized the potential harms of screening mammography, explained Dr. Hendrick.

You can't really compare having a call back for additional testing to dying of breast cancer.

"You can't really compare having a call back for additional testing to dying of breast cancer," he said. "They were comparing something with mild implications to something with huge implications. They looked at the potential harms of screening without looking at lives saved from a proper perspective."

The actual number of false-positive tests is also actually quite low, Dr. Hendrick noted.
For a woman 40 to 49 years who receives annual screening, a false-positive test will occur once every 10 years on average.
She will be recalled for additional imaging once every 12 years and undergo a false-positive biopsy once every 149 years.
A missed malignancy will happen once every 1000 years.

In the USPSTF report, the harms of unnecessary recall for additional imaging were emphasized, the authors note. However, "this harm can be mitigated if women elect real-time screening interpretation with same-visit diagnostic imaging offered at many [American] facilities, . . . but this option was not mentioned by the USPSTF report."

May Dissuade Payors

Because the new recommendations were made by a federal panel, they do have an effect on healthcare decisions, Dr. Hendrick said.

In fact, the guidelines could have dissuaded some women from having a screening mammography, and could influence reimbursement from Medicare, Medicaid, and private payors, he added.

The USPSTF recommendations have done potential damage to women's health.

"The USPSTF recommendations have done potential damage to women's health by failing to seize the singular opportunity to both improve mammography in the United States and to increase screening mammography compliance," say the authors.

Dr. Hendrick reports being a consultant to GE Healthcare and serving on the medical advisory boards of the Koning Corporation and Bracco, both of which develop and manufacture diagnostic imaging systems. Dr. Helvie reports receiving grant support from GE Healthcare.

AJR Am J Roentgenol. 2011;196:W112-W116. Abstract

Tuesday, February 1, 2011

Updated USDA Dietary Guidelines Released

From Medscape Medical News

Emma Hitt, PhD

January 31, 2011 — The seventh edition of the US Department of Agriculture guidelines for healthy eating were released online today and include 23 key recommendations for all Americans, as well as 6 additional recommendations for specific population groups.

US Department of Agriculture dietary guidelines were first developed in the United States in 1980, and the previous (sixth edition) guidelines were released in January 2005. For the latest guidelines, a panel of 13 nutrition experts was convened to determine whether revisions were warranted, and to provide suggestions.

Linda Van Horn, PhD, RD, LD, from Northwestern University in Chicago, Illinois, chaired the 13-member Dietary Guideline Advisory Committee.
For 18 months, the committee reviewed the scientific and medical literature regarding the role of diet and nutrition in health promotion and disease prevention.

"The overarching differences include emphases on managing body weight through all life stages and on proper nutrition for children throughout," the authors note. "Also, research on eating patterns is incorporated for the first time, and the eating patterns presented now include vegetarian adaptations," they add.

The report, which includes recommendations for Americans aged 2 years and older, as well as those at increased risk of chronic disease, incorporates 2 new chapters: "The Total Diet: Combining Nutrients, Consuming Food" and "Translating and Integrating the Evidence: A Call to Action."

"Taken together, the Dietary Guidelines recommendations encompass two overarching concepts," Dr. Van Horn and colleagues write in the executive summary.
These are to "maintain calorie balance over time to achieve and sustain a healthy weight," and to "focus on consuming nutrient-dense foods and beverages."

With respect to maintaining calorie balance and a healthy weight, the authors suggest that "people who are most successful at achieving and maintaining a healthy weight do so through continued attention to consuming only enough calories from foods and beverages to meet their needs and by being physically active."

They add that a healthy eating pattern "limits intake of sodium, solid fats, added sugars, and refined grains and emphasizes nutrient-dense foods and beverages." These include "vegetables, fruits, whole grains, fat-free or low-fat milk and milk products, seafood, lean meats and poultry, eggs, beans and peas, and nuts and seeds."

Some Foods and Nutrients Should Decrease, Some Should Increase

The new guidelines specifically suggest decreasing the intake of various foods and nutrients, including limiting sodium to 1500 mg in about half the US population. Consumption of saturated fats, dietary cholesterol, trans fatty acids, solid fats, added sugars, and refined grains should all be limited. If alcohol is consumed, it should be consumed in moderation, the guidelines state.

In contrast, intake of vegetables, fruits, grains, and fat-free and low-fat dairy products should all be increased. Lean proteins including seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds should be emphasized.

The guidelines also suggest that foods providing more potassium, dietary fiber, calcium, and vitamin D should be selected. "These foods include vegetables, fruits, whole grains, and milk and milk products."

Guidelines for women who are pregnant or breast-feeding or who wish to become pregnant, as well as all individuals aged 50 years or older, are also included.

Professional Associations Respond to New Guidelines

Professional associations with a stake in nutrition have spoken out about the new guidelines. The American Institute for Cancer Research (AICR) states in a written release that it welcomes the 2010 Dietary Guidelines for Americans, and that it strongly supports the emphasis on plant-based diets.

"For years, the science on cancer risk has shown that diets emphasizing a variety of vegetables, fruits, whole grains and beans are cancer-protective," notes Susan Higginbotham, RD, PhD, director of research at AICR, in a statement.

"A plant-based diet means moderating meat intake, not eliminating it altogether," Dr. Higginbotham said. "We're thrilled to see obesity prevention, and thus cancer prevention, being placed front-and-center, where they belong."

However, the American Heart Association maintains that the new guidance for sodium content is too high. Although the dietary recommendations advise people at risk for high blood pressure or who already have hypertension to reduce daily sodium intake to 1500 mg, the rest of the population is still advised to limit intake to 2300 mg sodium per day.

"The [American Heart Association] recommends a daily sodium consumption limit of less than 1500 mg a day for all Americans, and is concerned that this two-part recommendation does not go far enough to protect the health of all Americans," the organization states in a news release.

Meanwhile the American Society of Nutrition congratulates the US Department of Agriculture and the Department of Health and Human Services on issuance of the 2010 Dietary Guidelines.

American Society of Nutrition spokesperson Connie Weaver, PhD, who served on the 2005 Committee, notes that the "most impressive new aspect of the 2010 Dietary Guidelines is the call to action for all sectors of the society to become involved in ensuring that all Americans have access to nutritious foods and opportunities for physical activity and to facilitate individual behavior change through environmental strategies."

USDA. Dietary Guidelines for Americans, 2010. Released January 31, 2011. Full text