CHICAGO—Patients with high blood pressure who take calcium channel blockers and diuretics have an increased risk for cardiovascular disease (CVD) death compared to patients who take beta-blockers plus diuretics, according to a study in the December 15 issue of JAMA. Other findings indicate that diuretics may be the preferred single high blood pressure medication in preventing CVD complications.

According to background information in the article, several types of medications are used to treat high blood pressure, including diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers. While previous research has indicated that diuretics are equal or superior to other high blood pressure medications as the first step as monotherapy, most patients with hypertension require more than one drug class to control hypertension. It has been unresolved as to which of the other drug classes added to diuretics has better effects on cardiovascular complications.

Sylvia Wassertheil-Smoller, Ph.D., of the Albert Einstein College of Medicine, Bronx, N.Y., and colleagues examined the relation of different classes of antihypertensive drugs to the incidence of coronary heart disease, stroke, and CVD death. The researchers analyzed data for women with hypertension enrolled in the Women's Health Initiative Observational Study, a multicenter study of 93,676 women aged 50 to 79 years at baseline (1994-1998), assessed for an average of 5.9 years.

Among 30,219 women with hypertension but no history of CVD, 19,889 were on pharmacological antihypertensive treatment, of whom 11,294 (57 percent) were receiving monotherapy with an ACE inhibitor, beta-blocker, calcium channel blocker, or diuretic, and 4,493 (23 percent) were treated at baseline with a combination of diuretic plus either ACE inhibitor, beta-blocker, or calcium channel blocker or ACE inhibitor plus calcium channel blocker. The researchers found that among 2-drug-class combinations, diuretics plus calcium channel blockers were associated with approximately doubling of the risk of CVD death compared with diuretics plus beta-blockers. For events related to coronary heart disease or stroke, diuretics plus ACE inhibitors or calcium channel blockers did not differ from diuretics plus beta-blockers. Monotherapy with calcium channel blockers vs. diuretics was associated with a 55 percent increased risk of CVD death.

CHICAGO—The longer an immigrant lives in the U.S. the more likely they are to be obese, according to a study in the December 15 issue of JAMA.

Since the 1980s, the U.S. population has become more obese, according to background information in the article. However, little information is available about the prevalence of obesity among immigrants, the fastest growing segment of the U.S. population, currently comprising more than 11 percent of the total U.S. population and an even larger proportion of many minority groups. Immigrants generally originate from countries where the prevalence of obesity is lower than that of the United States, but adopting U.S. norms over time may lead to an increasing prevalence of obesity among this population.

Mita Sanghavi Goel, M.D., M.P.H., of the Feinberg School of Medicine, Northwestern University, Chicago, and colleagues examined the relationship between prevalence of obesity and years of U.S. residence among immigrants nationally, and explored whether counseling about diet and exercise may differ between immigrants and U.S.-born adults. The researchers used data from the 2000 National Health Interview Survey. Information collected included body mass index (BMI, measured as weight in kilograms divided by the square of height in meters) and rates of diet and exercise counseling.

Of 32,374 respondents (representing an estimated 201 million adults in the United States), 14 percent were immigrants. The prevalence of obesity was 16 percent among immigrants and 22 percent among US-born individuals. The researchers found that the prevalence of obesity was 8 percent among immigrants living in the United States for less than 1 year, but 19 percent among those living in the United States for more than 15 years. After adjusting for age, sociodemographic, and lifestyle factors, living in the United States for 10 to 15 years was associated with a BMI increase of 0.88, while living in the United States for at least 15 years was associated with a BMI increase of 1.39. The association for more than 15 years was significant for all immigrant subgroups, including whites, Latinos and Asians, but not foreign-born blacks. "To illustrate the impact, for a typical 5'4" immigrant woman and a typical 5'9" immigrant man this amounts to an excess 9 lb. (4.05 kg) and 11 lb. (4.95 kg), respectively, in addition to any weight gained due to aging or other factors," the authors write.

The study also found that immigrants were less likely than U.S.-born individuals to report discussing diet and exercise with clinicians (18 percent vs. 24 percent; 19 percent vs. 23 percent, respectively).

CHICAGO—An analysis of a sample of Ayurvedic herbal medicine products found that 20 percent contained metals such as lead, mercury and arsenic at levels that could be toxic if taken as directed, according to a study in the December 15 issue of JAMA.

According to background information in the article, approximately 80 percent of India's one billion population uses Ayurveda, a medical system that originated in India more than 2000 years ago and greatly relies on herbal medicine products (HMPs). Ayurveda's popularity in Western countries has increased. Because Ayurvedic HMPs are marketed as dietary supplements, they are regulated under the Dietary Supplement Health and Education Act (DSHEA), which does not require proof of safety or efficacy prior to marketing. Herbs, minerals and metals are used in Ayurvedic HMPs. Recent reports of serious lead poisoning associated with taking Ayurvedic HMPs were the impetus for the current study.

Robert B. Saper, M.D., M.P.H., formerly of Harvard Medical School, Boston, (currently with the Boston University School of Medicine) and colleagues examined Ayurvedic HMPs manufactured in South Asia and sold in Boston-area stores in order to examine their heavy metal content. From April to October 2003, the researchers purchased 70 different Ayurvedic HMPs at stores within 20 miles of Boston City Hall. Concentrations of lead, mercury and arsenic were measured in the samples. The potential amount of daily metal ingestion, estimated by using manufacturers' dosage recommendations, was compared to U.S. Pharmacopeia and U.S. Environmental Protection Agency regulatory standards.

The researchers found that 14 (20 percent) of the 70 HMPs contained lead, mercury and/or arsenic, and that if taken as recommended by the manufacturer, each of these could result in heavy metal intake above the published regulatory standards. Lead was found in 13 HMPs; mercury in six HMPs; and arsenic in six HMPs. Half of the HMPs containing potentially toxic heavy metals were recommended for children. The 14 HMPs containing heavy metals were manufactured by 11 different companies. Of the 30 stores visited, 24 sold at least one heavy metal-containing HMP.

"...the presence of heavy metals in Ayurvedic HMPs and the numerous reports of associated toxicity may have important public health, clinical, and policy implications in the United States and abroad. Although the prevalence of heavy metal-containing Ayurvedic HMP use is unknown, the number of individuals at potential risk is substantial," the authors write. "Public health and community organizations should consider issuing advisories to current or previous Ayurvedic HMP users, encouraging them to consult their physicians about heavy metal screening."

COMBINING CALCIUM CHANNEL BLOCKERS AND DIURETICS TO TREAT HIGH BLOOD PRESSURE IN OLDER WOMEN ASSOCIATED WITH GREATER RISK OF HEART PROBLEMS AND DEATH