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Am Fam Physician. 1999;60(1):319-328

Update on Intake of Folic Acid by Women

The Centers for Disease Control and Prevention (CDC) reports that most women still do not know that an adequate intake of folic acid can prevent some serious birth defects. Even fewer women know that folic acid must be taken before and during the first few weeks of pregnancy, and most women still do not get any information about folic acid from their physicians, according to a report in the April 30, 1999, issue of Morbidity and Mortality Weekly Report. The report summarizes the knowledge and practices regarding folic acid among women of child-bearing age in the United States and compares these results with those from a similar survey conducted in 1995 before the Public Health Service recommended that all women of childbearing age consume 400 μg of folic acid daily to prevent serious birth defects of the spine and brain.

Overall, 68 percent of women reported ever having heard or read about folic acid, a 31 percent increase from 52 percent in 1995. Of all women surveyed, only 13 percent knew that folic acid helps prevent birth defects, and only 7 percent knew that folic acid should be taken before pregnancy, compared with 5 percent and 2 percent in 1995, respectively.

In 1998, 32 percent of women reported taking a vitamin supplement containing folic acid on a daily basis, compared with 28 percent in 1995. Health care professionals were the sources of information for only one in five women surveyed who had heard of folic acid. The CDC believes that health care professionals have an important role in promoting preconceptional health, including daily intake of 400 μg of folic acid throughout the childbearing years of women.

The report also notes that the CDC, the March of Dimes and the National Council on Folic Acid have launched a national education campaign to get this message to women and their physicians. More information can be found on the Web site of the CDC at

Manual on Lupus for Health Care Professionals

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health has made available to health care professionals a new publication titled “Lupus: A Patient Care Guide for Nurses and Other Health Professionals.” The 144-page guide covers symptoms and diagnosis, advances in lupus research, laboratory tests for lupus diagnosis and evaluation, lupus medications, health care interventions for general and system-specific manifestations of lupus, psychosocial aspects and lupus information resources, including information sources, government agencies and nonprofit organizations. The guide also has 16 patient information sheets that can be reproduced.

Free, single copies of the guide are available by contacting Lupus Guide, National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse, NIAMS/National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892-3675; telephone: 301-495-4484; fax: 301-718-6366; e-mail: The entire text is also available on the NIAMS Web site at

Report on Implantable Neurostimulation Devices

The Health Technology Advisory Committee (HTAC) has published a report on implantable neurostimulation devices. HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The report includes guidelines for the use of spinal cord stimulation for pain management and in refractory angina pectoris; sacral nerve stimulation for control of urinary incontinence; vagus nerve stimulation for seizure control in epilepsy; and deep brain stimulation for tremor control. The safety and efficacy of these technologies is discussed, as well as future directions. The report also contains a list of additional contacts for information on neurostimulation.

Neurostimulation technologies modify electrical nerve activity. Following are two common requirements identified in the report for the safe and effective use of neurostimulation devices:

  • Use of neurostimulation devices should be considered only after more conservative therapies have proved ineffective in addressing a particular condition.

  • Patients who may be candidates for an implantable device should be referred to subspecialists with expertise in neurostimulation and the specific condition for which the device was designed.

This report and others published by HTAC may be obtained by calling 651-282-6374; e-mail: There is no charge for the reports. All HTAC reports are also available through the Internet at

AHCPR Pocket Guides for Health Prevention

The Agency for Health Care Policy and Research (AHCPR) has made available two pocket-sized guides containing the most current recommendations and other information in Spanish for the prevention or early detection of illnesses such as breast cancer, heart disease and lead poisoning in the Hispanic population. The guides provide information on topics ranging from dietary guidelines and child development to safety guidelines and the warning signs of depression.

The pocket guides are part of a national campaign called “Put Prevention into Practice,” which has the objective to increase and improve the provision of clinical prevention services and educate the public. “Guia de salud infantil” (“Child Health Guide”), publication no. APPIP 99-0013, contains recommendations from medical societies and public health authorities about examinations and tests, development, nutrition, physical activity and other topics in children's health. “Guia de salud personal” (“Personal Health Guide”), publication no. APPIP 99-0012, includes information about blood pressure, cholesterol, dental care, nutrition and other areas.

To order these guides in the Spanish version or the English version, call 800-358-9295 or write: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. Up to 200 copies may be ordered without charge. Another source for the guides is the AHCPR Web site at

New Home Test for Hepatitis C Virus

The first over-the-counter blood collection kit for testing for antibodies to hepatitis C virus has been approved by the U.S. Food and Drug Administration (FDA). According to the FDA, the user collects a sample of blood at home and mails it to a designated laboratory for analysis. The results are available by telephone and are kept confidential by use of an identification number.

In clinical trials that included about 1,200 persons, study participants used the home test kit and also had their blood obtained by a health care professional and tested. The test results obtained by home test and by a health care professional were similar. As part of the test system, the manufacturer of the home test provides a telemedicine service, which offers education and counseling about hepatitis C virus and, if desired, referral to a physician.

Individuals at high risk for acquiring hepatitis C virus include those who received blood transfusions or organ transplants before 1992; those who inject illegal drugs; persons who have used or been pricked with an infected needle; or those who engage in high-risk sexual behavior with a person infected with hepatitis C.

Technical Manual on Female Circumcision

The Health Resources and Services Administration (HRSA) and the Public Health Office on Women's Health are recommending a new technical manual for health care professionals titled “Caring for Women with Circumcision,” by the Research, Action and Information Network for the Bodily Integrity of Women (RAINBO). Female circumcision/female genital mutilation is a term used for a number of different cultural practices of cutting, removing and sometimes sewing up the external female genitalia.

The booklet includes background information on the social and cultural meanings of female circumcision. It discusses culturally sensitive counseling, education and outreach; legal status in the United States; reporting to authorities and counseling the patient on the law; special concerns of adolescents; and case studies.

For more information or to order copies of the manual, contact RAINBO, 915 Broadway, Ste. 1109, New York, NY 10010; telephone: 212-477-3318; fax: 212-477-4154. The RAINBO Web site address is

Early Detection of Kidney Disease

The National Kidney Foundation (NKF) has issued a position paper recommending widespread testing for proteinuria, which is a warning sign of kidney disease, stroke and coronary disease. According to the position paper, published in the May 1999 issue of the American Journal of Kidney Diseases, testing for protein in the urine should be included in routine office visits, especially for high-risk patients. High-risk patients include persons who have diabetes mellitus, high blood pressure or close relatives with those conditions. The NKF emphasizes that protein in the urine is more common in blacks, Hispanics, Native Americans, obese persons, elderly persons and persons with a family history of kidney disease.

In patients who test positive for protein in the urine, the NKF recommends repeat testing within three months. In those who continue to test positive, a referral to a nephrologist is recommended.

Publication of the position paper is part of the NKF's Proteinuria Albuminuria Risk Assessment Detection and Elimination (PARADE) program. The NKF Web address is

Warning About GBL-Related Products

A new group of products sold as sleep aids, muscle builders and “party drugs” present serious health dangers, according to the U.S. Food and Drug Administration (FDA). These products are chemically related to gamma butylactone (GBL) and gamma hydroxybutyric acid (GHB), substances that have proved to be significant health hazards. One of these is 1,4 butanediol (BD), declared potentially life-threatening by the FDA. BD slows breathing and can cause unconsciousness, vomiting, seizures and death.

Products that contain BD include Revitalize Plus, Serenity, Enliven, GHRE, SomatoPro, NRG3, Thunder Nectar and Weight Belt Cleaner, according to the FDA. These products are listed as “party drugs” on Internet sites, advertised in muscle-building magazines and sold in health food stores as dietary supplements to help with sleep.

At least 122 adverse health effects have been associated with use of GBL, GHB and BD, including three deaths. Health authorities believe manufacturers are renaming their products and substituting BD for GBL. The effects of ingesting BD are just as dangerous as those of GHB and GBL.

Atrovent Aerosol and Peanut Allergy

The Institute for Safe Medication Practices (ISMP) has issued an alert stating that the use of ipratropium aerosol (Atrovent inhalation aerosol) is contraindicated in patients with hypersensitivity to soya lecithin or related products, such as soybeans and peanuts. The alert, published in the October 21, 1998, issue of ISMP Medication Safety Alert, states that neither the package label nor the patient instruction sheet mentions a contraindication for patients with peanut allergy. The ISMP points out that patients with peanut allergy can use Atrovent nasal spray or inhalation solution because neither contains soya lecithin. The ISMP has recommended that the manufacturer strengthen warnings about peanut allergies in patient and professional information. For more information on safe medication practices, visit the ISMP Web site at

Recommendations for Prevention of STDs in Blacks

The National Medical Association (NMA), a medical society representing black physicians, has released recommendations for the prevention of sexually transmitted diseases (STDs) in black adolescents. According to the NMA, a disparaging number of black youths are contracting STDs, which points to an increased risk for contracting human immunodeficiency virus. NMA believes that abstinence is the preferred method for prevention of STDs in black youths. However, NMA recommends encouraging the use of latex condoms for adolescents who are sexually active, and the group believes condoms should be distributed through the public school system. NMA recommends sexual education programs for youths in the schools that choose to distribute condoms. For more information, contact NMA, 1012 10th St., N.W., Washington, D.C. 20001; telephone: 202-347-1895; fax: 202-842-3293.

Use of Anabolic Steroids in Athletes

Stronger multifaceted prevention programs need to be implemented to stem the increased use of anabolic steroids to enhance athletic performance and physical appearance, according to a statement from the American College of Sports Medicine (ACSM). The ACSM reports that it is becoming increasingly obvious that anabolic steroid use is not just confined to collegiate, professional and Olympic athletes, but is also prevalent among junior high and high school students. Lifetime prevalence rates for steroid use among male adolescents range from 4 to 12 percent, and an increase in steroid use has been noted in female adolescents.

While laws prohibiting the use of anabolic steroids have had some impact, the ACSM believes that adolescents need to hear a consistent message against steroid use on a continual basis. They should be provided with the latest and most accurate information on sports nutrition, strength training, conditioning and use of supplements. The ACSM believes that adolescents need strong moral and ethical leadership to help them establish boundaries that should not be crossed in the pursuit of victory.

More information may be obtained from the ACSM, P.O. Box 1440, Indianapolis, IN 46206-1440; telephone: 317-637-9200; fax: 317-634-7817.

AAFP's 1999 Annual Scientific Assembly

The 1999 Annual Scientific Assembly of the American Academy of Family Physicians (AAFP) will be held in Orlando, Fla., from September 15 through September 19.

The Scientific Program offers up to 47.5 hours of prescribed AAFP continuing medical education (CME) credit. CME credit is available for a wide variety of activities, including clinical seminars, audiovisual and computer options, lectures, dialogue sessions and clinical procedures workshops. Twenty-seven evening CME courses will be available at this year's meeting. Also of interest are the scientific exhibits, physician placement exhibits and a wide array of technical exhibits. AAFP members are invited to participate in the activities of the policy-making Congress of Delegates, which convenes September 14 through September 16. Complimentary evening events include the fellowship convocation, the presidents' reception and an all-member event. Numerous family activities, guest courses and activities for children will be available.

For the first time this year, members may register online ( in addition to registering by mail or by fax. Early registration is encouraged to ensure adequate accommodations and access to desired courses that require preregistration. After August 11, registration for Assembly activities will be limited to on-site registration. Information can be obtained by calling the AAFP Assembly hotline (800-926-6890) or by e-mailing your request (

Orlistat for Obesity

The U.S. Food and Drug Administration has approved orlistat (Xenical), a new drug to treat obesity. Orlistat is the first drug in a new class of nonsystemically acting antiobesity drugs known as lipase inhibitors. Unlike other obesity drugs, orlistat prevents enzymes in the gastrointestinal tract from breaking down dietary fats into smaller molecules that can be absorbed in the body. Absorption of fat is decreased by about 30 percent. Orlistat is indicated in obese persons with an initial body mass index (BMI) of 30 or more, or in persons with other risk factors, such as high blood pressure, high cholesterol levels and diabetes, with an initial BMI of 27 or more. It is also indicated to reduce the risk for weight regain after previous weight loss.

In clinical trials, persons who received orlistat and modified their diet to include up to 30 percent of calories from fat lost an average of 10 percent of their body weight within one year. The recommended dose of orlistat is one capsule with each main meal that includes fat.

The most common side effects associated with orlistat are gastrointestinal symptoms such as oily spotting, flatulence with discharge, fecal urgency, fatty or oily stool, oily evacuation, increased defecation and fecal incontinence. It is contraindicated in patients with chronic malabsorption syndrome or cholestasis. Additional information on orlistat may be obtained by calling 800-746-5456 or at the following Web address:

The Cancer Journey: A Video Training Program for Health Care Professionals

The National Cancer Institute (NCI) has made available a video training program designed to provide health professionals with information needed to respond effectively to issues facing survivors of cancer. “The Cancer Journey: Issues for Survivors” consists of two components: a leader's guide and a 30-minute video. The leader's guide includes a resource section to assist health professionals in identifying informational resources for training programs. The video covers the following issues for cancer survivors: psychosocial, physiologic, employment, insurance, financial and legal. To order the training program, contact the NCI's cancer information service at 800-4-CANCER.

Near-Sightedness and Light Exposure During Sleep

Children under the age of two years who sleep in a dark room are much less likely to develop myopia later in life than those children who sleep with a night light, according to a study published in the May 13 issue of Nature. Children older than two years do not seem to be at risk. The investigators believe that artificial light must trigger changes only in the rapidly developing eye of an infant or a toddler.

Of the children in the study who were currently aged two to 16 years and who had slept in darkness before the age of two years, 10 percent were found to be myopic. Of the children who had slept with a night light on before two years, 34 percent were myopic at the time of the study. Of the children who had slept at night with a room light on before the age of two years, 55 percent were myopic—more than a fivefold increase over the children who slept in darkness during early childhood. The investigators believe that the proliferation of electric lights in the past century may be one of the factors in the high incidence of myopia in developed nations.

The investigation was conducted at the Children's Hospital of Philadelphia and the University of Pennsylvania Medical Center, Philadelphia. The investigators emphasize that more research is needed on this subject.

FDA Warning for Arthritis Drug

The U.S. Food and Drug Administration (FDA) has issued a warning to physicians concerning the use of etanercept (Enbrel), a new treatment for patients with moderate to severe rheumatoid arthritis. Some patients receiving etanercept have contracted serious infections; six patients died within two to 16 weeks after starting treatment with the drug.

When etanercept was approved in November 1998, the label stated that the drug is contraindicated in patients with sepsis and should be discontinued if a patient contracts a serious infection. The warning has now been expanded to include patients with any active infection, including chronic or localized infections. In addition, it is now recommended that patients who acquire an infection while being treated with etanercept be monitored closely.

The FDA reports that it is not known if etanercept is actually the cause of the serious infection in patients with rheumatoid arthritis, but physicians should consider these reports when assessing the risks and benefits of the medication.

The FDA requests that all cases of serious infection or sepsis occurring in patients receiving etanercept be reported to the Medwatch program by telephone (800-FDA-1088); by fax: (800-FDA-0178); or by mail (Med-watch, HF-1, FDA, 5600 Fishers Lane, Rockville, MD 20857.) Reports can also be made through the Internet at

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Copyright © 1999 by the American Academy of Family Physicians.

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