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October 1999

House Passes Bipartisan Patients' Rights Bill
October 8, 1999

The House of Representatives Thursday defied the Republican leadership and passed a bipartisan patient protection bill that would, among other things, dramatically expand patients' right to sue if they are injured as a result of a health plan's denial of care.

By a vote of 275-181 members passed the 'Bipartisan Consensus Managed Care Improvement Act,' sponsored by Reps. Charlie Norwood (R-GA) and John Dingell (D-MI). In addition to requiring health plans to offer more choices, to pay for emergency room care, and to provide easier access to specialists, the lawsuit provisions are "about the right to ask people to be responsible for their actions," said Norwood.

The bill was by far the most sweeping of the four alternatives offered to the House. Forces supporting the measure were not confident of victory until the defeat of a measure offered by Reps. Tom Coburn (R-OK) and John Shadegg (R-AZ), and backed by the Republican leadership. While leaders worked hard Wednesday and Thursday to convince Republicans to vote for the Coburn-Shadegg measure, 29 Republicans defected and the measure failed by a vote of 238-193.

Earlier, the House turned back a proposal by Rep. John Boehner (R-OH), that would not have expanded the right to sue, by a vote of 284-145. Also failing by 269-160, was a proposal by Reps. Amo Houghton (R-NY) and Lindsey Graham (R-SC), that would have, in effect, combined the broader patient protections from the Norwood-Dingell bill with the more limited right to sue of the Coburn-Shadegg measure.

Under the rule forced through the House over Democratic objections, the patient protection measure will now be merged with the insurance 'access' bill passed by the House Wednesday, then sent to conference with the Senate "Patients' Bill of Rights" passed in July. President Clinton has threatened to veto the access bill, which includes both tax breaks for individuals and the ability of small businesses to band together. A statement from the administration said the bill would be vetoed because it would not help many of the uninsured and has no mechanism to offset its estimated $48 billion cost.

Democrats also complained that Republicans did not let them offer an amendment to the Norwood-Dingell bill to offset its estimated $7 billion cost. President Clinton on Thursday sent a letter to the House urging members to vote for the bill, but vowing not to sign into law any measure unless it is fully financed.

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Sniff, Don't Blow, When you have a Cold.

When you had a cold as a child, your mother probably told you to stop sniffling and blow your nose. New research shows that might not be a good idea -- and may even make your cold worse.

In findings that are sure to anger tissue and handkerchief manufacturers, researchers from the University of Virginia have found that blowing your nose creates enough pressure to propel mucus into your sinuses. This could worsen congestion in the sinuses and contribute to making you feel lousy when you have a cold.

"I learned from my mamma it was important to blow my nose when I had a cold, but that goes against the way God designed the system," said Dr. Owen Hendley, a professor of pediatrics at the University of Virginia School of Medicine and lead author of the study that was presented recently at the Interscience Conference on Antimicrobial Agents and Chemotherapy in San Francisco. "The normal mucus flow is from the front of the nose to the back, and with nose blowing you reverse that."

Hendley and his colleagues decided to figure out how mucus finds its way into the sinuses after they read previous research that showed mucus in the sinuses of people with colds includes air bubbles.

"We wondered, 'Gee. How did the bubbles get there?'" Hendley said.

In the initial experiment, researchers measured the pressure in the nose during coughing, sneezing and blowing the nose by inserting pressure sensors into the nasal airways of four volunteers. (Hendley was one of them).

They found that the pressure in the nose increased a bit during coughing and sneezing to about 5 to 10 millimeters of mercury, while nose blowing sent the pressure in the nose skyrocketing to about 70 to 80 millimeters of mercury.

Taking into the account how thick mucus is, researchers created a fluid model to determine how much pressure would push the mucus into the small opening that connects the nasal passage to the sinus. The sinus cavities are connected to the nose by tiny tubes about 2 to 3 millimeters in diameter, or about the size of a pencil point.

The sinus flow

"It was obvious that during coughing and sneezing there would not be flow into the sinus, whereas [with] the pressure generated during one nose blow, you could very clearly move mucus into the sinus," Hendley said.

To confirm those findings, they had another group of 10 volunteers lie on their backs with their chins pointed down while coughing, sneezing and blowing their noses. To determine the movement of the mucus, they put a dye in the back of the nose that can be seen on an X-ray.

In the volunteers who coughed and sneezed, no dye moved into the sinuses. In those who blew their nose, dye clearly showed up in the sinuses, Hendley said.

More research needs to be done before Hendley will blow the whistle on nose blowing, but he says he's likely to do a lot more sniffling. An earlier study showed that adults with colds blow their noses an average of 45 times a day during the first three days of illness, creating ample opportunity to push nasal secretions into the sinus.

"If I had a lot of problems with sinus congestion when I had a cold, I might be more likely now to sniff it back," he said. "Will it make a difference? We don't know yet."

What To Do

People with colds should consider over-the-counter cold medications that reduce nasal fluid production, not only to relieve symptoms, but because they may help prevent the spread of the cold to the sinuses, Hendley said. Start treatment early for maximum benefit.

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Herbal Prostate Drug Goes Mainstream
October 8, 1999

If you're male and you live long enough, there's virtually no escaping the indignities and agonies of an enlarged prostate.

In young men, this gland, which surrounds the urethra (the tube through which urine passes) and is the size of a chestnut, secretes part of the seminal fluid that nourishes sperm and speeds it on its way.

But over the years, assuming a man has normal levels of the hormone testosterone, the prostate enlarges - sometimes to the size of a grapefruit - and presses on the urethra. This causes incomplete emptying of the bladder, the need to urinate often and urgently, a weak "stream" and - most annoying - the need to get up frequently at night to urinate.

For one in three men, benign prostatic hyperplasia, or BPH, gets bad enough to warrant medical intervention - prescription drugs or one of several types of minimally invasive surgery.

Increasingly, however, men are using herbal remedies instead of or in addition to the traditional treatments - mainly preparations of saw palmetto but also pumpkin seeds, nettle roots, Swedish pollen, and Pygeum africanum, the bark of an African tree.

The question is, should they?
The answer is a cautious yes, with an important caveat. As with every other product on the $4 billion-a-year herbal market, these "botanicals" are not reviewed by the US Food and Drug Administration. That means it's difficult to know how truly safe or effective they are.

On the other hand, there is a growing body of evidence - albeit small, flawed studies - that suggests that saw palmetto, at least in some preparations, is safe, has few side effects, and may relieve BPH symptoms. Data on the other herbal BPH remedies, however, are scant.

Saw palmetto extract, which comes from the berries of a dwarf palm tree, is "one of the better" herbal products, says plant medicine researcher Varro Tyler, dean emeritus of the Purdue University School of Pharmacy and Pharmacal Sciences.

In a recent editorial in the journal Urology, Tyler and Dr. Leonard S. Marks, a UCLA urologist, noted that one large study showed a saw palmetto brand called Permixon (sold in Europe) is safe and causes no changes on standard blood tests, including PSA tests.

(The PSA, or prostate specific antigen, test is used to detect prostate cancer, and doctors had feared that saw palmetto might alter PSA scores, making it harder to detect cancer.)

And, Permixon is as effective as and less likely to cause impotence than Proscar, a prescription drug often used to treat BPH, according to a 1996 study of 1,098 men.

But Permixon, which is not available in the United States, is relatively easy to study because it contains no other ingredients.

By contrast, many of the 30-odd preparations available on store shelves in this country contain a mish-mash of ingredients, making it impossible to know what agent is doing what.

"Permixon is very highly purified," and very safe, says Dr. John McConnell, a University of Texas urologist who heads a committee of the American Urological Association charged with assessing treatments, including herbals, for BPH.

"God knows what's in these other preparations. Each one would have to be evaluated" separately, he says. "It boggles the mind how one would test that."

That said, a 1998 analysis of pooled data from 18 studies involving 2,939 men nevertheless concluded that saw palmetto, in a number of different preparations, does seem to be better than placebo in relieving BPH symptoms. This analysis of saw palmetto (also called serenoa repens) was published last November in the Journal of the American Medical Association.

In other words, taken together, the data on saw palmetto's effectiveness, flawed though some of it is, is "considerable," even though, as Tyler and Marks point out, none of the studies alone would probably meet FDA standards for approval of a new drug.

Curiously, nobody really knows how it might work. One hypothesis is that it may affect hormone levels, but the lack of side effects, such as decreased libido, argues against this.

What it may do, though again it's not clear how, is shrink prostate tissue. At a meeting of the American Urological Association in May, Marks reported on his double-blind study of 41 men who had biopsies (or tissue samples) of their prostates taken at the beginning and end of a 6-month period.

He found a reduction in prostate size in men who took a saw palmetto and nettle root preparation made by Nutrilite compared to those in men who took a placebo, or dummy drug.

Marks' team suspected the herbal remedy might act by inducing cell death or blocking blood-vessel growth in prostate tissue, but neither of those hypotheses panned out, he says, suggesting that it may work through some still-unknown "novel mechanism."

The Marks study, in which men taking saw palmetto reported about the same level of improvement in clinical symptoms - 25 percent - as those on placebo, highlights another conundrum of prostate research: Many remedies, even prescription drugs, seem to be only partially effective, and many patients taking placebos report a mild improvement in symptoms, too.

In fact, overall, about 50 percent of men who get a placebo in BPH drug studies say their symptoms get better, perhaps through the expectation of improvement, notes Dr. Kevin R. Loughlin, director of urological research at Brigham and Women's Hospital in Boston.

It's common for men to give "mixed reviews" to both herbal remedies and prescription drugs for BPH, says Dr. Isadore Rosenfeld, a cardiologist at the Weill School of Medicine at Cornell University in New York City and author of several books on alternative medicine.

With saw palmetto, he says, "some men say yes, it helps, others say no. It's the same with Proscar," the prescription drug, which can take three to six months to take effect, he says.

Les Hellenack, 70-year-old Watertown computer consultant who's been taking both saw palmetto and Proscar for more than five years, puts it this way:

"I can't tell which is helping, but between them, they both seem to help."

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Drug Helps Men With Osteoporosis
October 7, 1999

Men with the bone-thinning disease osteoporosis respond to treatment with alendronate, a drug already used to treat the disease in women, US researchers report.

Dr. Eric Orwoll of the Oregon Health Sciences University in Portland, reported recently at the annual meeting of the American Society for Bone and Mineral Research that the bisphosphonate alendronate was successful in improving bone density at several sites in the male skeleton, in reducing the incidence of fractures, and in preventing loss of height.

``This is the first documentation of a widely applicable treatment for osteoporotic men,'' he said in his presentation.

Bisphosphonates, in use for about 10 years, are oral drugs that can prevent the breakdown of bone in patients who have osteoporosis, cancer, Paget's disease, and other bone disorders. Alendronate — sold under the name Fosamax by Merck & Co. — is one of several bisphosphonates on the market in the US.

Orwoll and his colleagues studied 241 men, average age 63 years, who had osteoporosis, defined by bone density testing of the thighbone or by a history of osteoporotic fractures. The men were enrolled in the study for 2 years, with 146 taking 10 milligrams of alendronate per day, and 95 taking a placebo, or ''dummy'' pill. All men in the trial also received vitamin D and calcium supplements.

At the start of the trial, 36% of all the men had low testosterone levels in their blood, which is associated with osteoporosis in men, and 50% had vertebral fractures at that time. The fractures were found by x-ray and were not necessarily symptomatic, Orwoll noted.

Men on alendronate had an increased bone mineral density of 7.1% in their lumbar vertebrae, 2.5% increase at the femoral neck (part of the thighbone), and a 4.4% increase at the trochanter (another part of the thighbone).

In contrast, men on placebo had a bone mineral density increase of only 1.8% at the lumbar spine and 1.3% at the trochanter, and decrease of 0.1% at the femoral neck.

Height loss was four times greater in the men who were taking placebo than in men taking alendronate.

Men who were testosterone-deficient and took alendronate had increases in bone mineral density similar to those men taking alendronate who had normal testosterone levels at the start of the trial, according to the study findings.

Orwoll concluded that alendronate is a safe and effective drug for treatment of osteoporosis in men.

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Soy May Help Prevent Prostate Cancer
Oct. 6, 1999

If you're a man who says phooey to tofu, consider this: A cup of soy milk or a daily serving of tofu may prevent you from getting prostate cancer, according to recent studies.

"The evidence linking a positive effect between soy and prostate cancer looks very encouraging," says Mark Messina, an associate professor at Loma Linda University in California.

Scientific interest in soy was sparked by the fact that very few Japanese men die from prostrate cancer, Messina explains. "An earlier study of men in Japan, about 10 years ago, showed that men who consumed tofu five times a week had their risk for prostate cancer reduced by 65 percent."

American men are almost five times as likely to die from prostate cancer than Japanese men. About 179,300 new cases were diagnosed in the United States during 1999, according to the American Cancer Society. About 37,000 men died of it in 1999. It's the second leading cause of cancer death in men.

Messina says Japanese men do "get small prostate tumors, but apparently the tofu delays the onset of cancer, or slows the growth of the tumors."

"The evidence from Japan is quite convincing, if anecdotal," says Claude Gerard, the president of The American Prostate Society in Hanover, Md. "The rate of prostate cancer in Japan is the same as it is in the United States, but the death rate from prostate cancer is about zero compared to us."

"The rest of the picture is, when Japanese men move to Hawaii and take on an American diet, they have the same rate of death as we do," Gerard adds.

The Adventist study

A recent study of Seventh Day Adventists in California found that those who drank "one cup to two cups of soy milk, at least once a day," also reduced their risk for prostate cancer -- by 70 percent. Among Adventists, 40 percent are vegetarians, according to Messina, and use tofu or soy milk in their diets. This population was used in the study because of their controlled diet and lifestyle.

Soy's magic bullet may be isoflavones, chemicals that influence cell growth and regulation and behave like weak estrogens. Those who eat soy have high blood levels of the chemicals, which can barely be found in the blood of those who don't, according to Messina.

Mice studies show that soybean isoflavones tend to concentrate in prostate tissue. When scientists would implant prostate cancer cells in the animals, the cancer cells are "markedly inhibited," says Messina.

Messina presented his review last week at the 40th annual meeting of the American College of Nutrition held in Washington, D.C.

Both Messina and Gerard agree that American men should eat soy every day. "Adding a cup of soymilk or a single serving of tofu to your diet could delay the onset of prostate until you're 80," Messina says.

What To Do

Eating soy, unless you're allergic, probably won't hurt you, and it just may help. But if you think you're at risk for prostate cancer, consult your doctor. There is no definitive proof that a single item in the diet can either totally prevent or cure any kind of cancer.

Possible signs of prostate problems: difficulty urinating; needing to urinate frequently, especially at night; blood in the urine; pain or burning on urination; continuing pain in lower back, pelvis or upper thighs. Most of these symptoms may be similar to those caused by benign conditions.

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Exercise Benefits Elderly, Too
October 6, 1999

Doctors often err on the side of caution, and do not promote exercise for their elderly patients. But a leading British physician is recommending a more pro-active stance, encouraging doctors to get their elderly patients to be more physically active.

Dr. Marion McMurdo, of the University of Dundee in Scotland, told Reuters Health that ``regular physical activity is more important in old age than it is in youth.'' In view of the so-called 'graying' of many of the world's populations together with common fears among the elderly about the dependency of old age, ``effort should be invested in encouraging older people to be active and to maintain their independence for as long as possible,'' she explains.

Because people who pursue physical activity into their older years have been shown ``to enjoy more years of healthy disability-free life than inactive older people,'' McMurdo suggests that ``health professionals... be imaginative in helping older people identify a type of activity that they will enjoy.''

She notes that support from others — including friends, family members, and healthcare providers — is key to the successful implementation of and ``adherence to (a program) of regular activity.''

McMurdo comments that ``health professionals should be pro-active in talking to older people in a positive way about the potential benefits of activity in old age.'' These include ''less fatigue, (being) more alert, more energy, (and) better sleep,'' she says.

In her article published in the British Journal of Sports Medicine, McMurdo writes that ``public health advice has failed to shake off the 'high-tech' lycra-clad image of aerobic exercises and physical fitness and embrace the concept of health and (ordinary) physical activity — walking, dancing, gardening, or playing with the grandchildren.''

``You don't need to be a marathon runner to improve your health in old age,'' she says. ``In the past, we... overestimated the amount of activity required in old age to improve health.''

McMurdo offers several recommendations for those interested in beginning an exercise program. ``Find an activity you enjoy. Invite a friend or spouse to join you,'' she advises. For those who have not been active for many years, ``start slowly and build up gradually, increasing the amount of time on a weekly basis,'' she adds.

``Exercise is meant to be enjoyable so (participants) should be left feeling refreshed and invigorated,'' McMurdo tells Reuters Health. She reminds exercisers, however, that one's personal physician should be consulted prior to initiating a new exercise regimen. And, consistent with well-known public health pronouncements, McMurdo recommends that older folks avoid tobacco and try to maintain an appropriate weight.

Telling her medical colleagues to ``unwrap the cotton wool'' in which the elderly are being encased, McMurdo urges health professionals to take ``a leading role in passing on his important message: the best investment you can make for your old age is regular physical activity.''

SOURCE: British Journal of Sports Medicine 1999;33:295-300.

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Exercise May Help Cancer Victims
October 4, 1999

Even during treatment, Lance Armstrong kept up his training.

During the fall and winter of 1996 and 1997, after surgery to remove a cancerous testicle, the world-class cyclist received chemotherapy. Between bouts of chemotherapy, even as he was losing muscle, he rode. After therapy, he rode some more.

Last July, a fully recovered Armstrong won the most prestigious event in cycling — the Tour de France.

And, although researchers can't say whether Armstrong's training during treatment helped him beat the disease, they do say studies increasingly indicate that physical activity can help cancer patients.

"Based on my expertise, what would I recommend if my mum was diagnosed with breast cancer? I would recommend exercise," said Kerry S. Courneya,a researcher at the University of Alberta, Edmonton. The Canadian scientist's review of 24 studies on exercise and cancer was published in Annals of Behavioral Medicine.

The studies have limitations, Courneya said. But, taken together, they indicate that staying active while cancer is in an early stage can help people retain quality of life and retard the loss of strength and endurance that accompanies the disease and its treatment.

"Cancer patients, even though they are on chemotherapy or during radiation, show many of the same types of fitness benefits that many of the regular population would show," he said.

However, there are many forms of cancer, and the research does not cover all of them, so any conclusions must be limited to the types of cancers studied, Courneya cautioned. Most of the studies involved breast cancer.

The new research looks so promising that the American Cancer Society is revising its exercise recommendations, according to Colleen Doyle, director of nutrition and physical activity.

"It used to be there wasn't anything out there, so we would tell people, "Conserve your energy,"' Doyle said.

But, while the research indicates exercise can be helpful, there still are people who should not do it, Doyle said. These include people whose cancer has spread to the bone, or who have lost bone density as a side effect of cancer treatment, she said.

Similarly, treatment may result in nerve damage that can make a person prone to falls, and certain medications can affect major organs in ways that limit activity, she said.

"We will certainly recommend that people talk to their health care providers before they do anything," Doyle said.

The studies were too varied, and the numbers of people involved in each were too small, for Courneya to estimate the size of the benefits. But the scope of the benefits ranged from increased flexibility to decreased fatigue, depression and anxiety, the review found.

Those quality of life issues are very important to cancer patients. Restoring himself to health was less than 10 percent physical, Armstrong told a congressional hearing last week. "The big part of it is the psychological factor," he said.

Benefits do not require intense exercise to achieve, Courneya said, adding that moderate activity such as brisk walking was sufficient.

The way in which activity can improve the lives of cancer patients is not understood, Courneya said. However, moderate activity can improve immune functions that could fight help to fight cancer.

And exercise can reduce estrogen levels, which could help breast cancer patients because estrogen is considered to promote tumor growth, he said. Breast cancer patients who are obese also have worse odds, and exercise can help people to lose weight.

The field is too new to be able to tell if people who exercise will live longer than those who do not exercise, said Dr. Anne McTeirnan of the Fred Hutchinson Cancer Research Center in Seattle. However, the Fred Hutchinson center, the University of Southern California and the University of New Mexico are setting up a study to follow 1,200 women with breast cancer, and activity is one of the factors that will be examined, she said.

Exercise can help cancer patients get more out of life, provided the amount and type of exercise is calibrated to the patient's condition, said Pamela Massey, director of rehabilitation services at the M.D. Anderson Cancer Center in Houston.

Breast cancer patients who have had a mastectomy, for instance, might get a special focus on improving the strength and flexibility of their shoulder muscles, she said. A person with an advanced cancer might be encouraged to use a wheelchair, although not to the point of getting worn out, she said.

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Surfers At Risk For Ear Disorder
September 29, 1999

Surfers, especially those who spend the greatest amount of time riding waves, are more likely to develop bony lesions called exostoses in their ears, California researchers report.

In mild cases, the lesions are generally harmless, perhaps leading to complications such as wax build-up and an increased risk of infections of the outer ear. With severe lesions, however, hearing impairment may result and surgery may be needed.

The ear canal passes through the temporal bone, one of the skull bones. Cold water, such as that found in oceans, stimulates bone growth — so over time, exposing the ear canal to cold water can lead to bony lesions in the canal, lead researcher Dr. Brian J.F. Wong of the University of California at Irvine, and colleagues explain. Their report is published in the September issue of the Archives of Otolaryngology, Head and Neck Surgery.

According to the findings, 73.5% of 307 avid surfers in the study had such lesions, which are known as external auditory canal exostoses. The longer a person had been surfing, the more likely he or she was to have lesions, and the more severe those lesions were, the researchers report.

``Surfers, ocean swimmers, sailors and deep-water divers should be advised of the benefits of limiting cold-water exposure,'' Wong and colleagues suggest. ``Wearing ear molds, ear plugs, visored caps and hoods may prevent exostoses by preventing the entry of cold water into the external ear canal. Further research is required to determine whether the early use of such ear protection equipment will in fact prevent this disorder,'' they write.

Overall, 19.2% of surfers studied had signs of extra bone growth in their ear. ``Of 441 ears with exostoses, 54.2% were mild, 23.6% were moderate and 22.2% were severe,'' the authors note. Of surfers who had only been riding the waves for 10 years or less, about 45% had normal ear canals and 6% had severely obstructed ear canal. Among study participants who had been surfing for more than 20 years, just 9.1% had normal ear canals and 16.2% were severely affected, the researchers add.

More than 60% of surfers with no lesions had surfed for 10 years or less. By comparison, 82.4% of surfers with severe lesions had surfed for more than 10 years.

``A positive association exists between the amount of time individuals spend surfing and the presence and severity of exostoses of the external auditory canal,'' Wong and colleagues conclude.

SOURCE: Archives of Otolaryngology, Head and Neck Surgery 1999;125:969-972.

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Nutrition Education Boosts Nutrient Intake In Pregnancy
October 6, 1999

Results of a new study of low-income pregnant women indicate that nutrition education during pregnancy has a positive impact on folate and iron intake. The study was presented here at the American College of Nutrition's 40th annual meeting held in Washington, DC.

``Health professionals often focus on a pregnant woman's weight gain and overlook whether or not she receives the vital nutrients necessary for healthy fetus development,'' said lead researcher Dr. Shahla Wunderlich of Montclair State University in Upper Montclair, New Jersey.

Folate prevents neural tube defects, which affect the brain and spinal cord, said Wunderlich. Liver, breakfast cereals, lentils, spinach, asparagus, and beans are good sources of folate.

Iron helps blood production and cell growth during pregnancy. Deficiency can impact cognitive function (memory and learning) in children, and also results in low birth weight and impaired coordination in infants. Significant iron sources are red meats, fish, poultry, shellfish, eggs, legumes, and dried fruits.

In the study, Wunderlich and colleagues gathered lab data and food records of 25 pregnant women at Shore Memorial Hospital in Somers Point, New Jersey, upon registration and at both 28 weeks and 36 weeks of gestation. The women received two one-on-one nutrition education sessions during the third trimester.

A diet analysis of 26 nutrients showed that average iron intake was lowest, Wunderlich said. Upon registration, the mean iron intake for the recommended dietary allowance (RDA) for pregnant women was 56%. It was 70% at 28 weeks of pregnancy and 67% at 36 weeks. ``Sixty-seven percent is not good enough. We would like to see these women show at least 75% of the RDA or more,'' Wunderlich said.

The women showed better improvement in their folate intake during the study. The mean folate intake at registration for these women was 48% of the RDA for pregnant women, 66% at 28 weeks and 74% at 36 weeks gestation, Wunderlich told Reuters Health.

``In the future, we would like to explore more effective nutrition education methods, such as computer-assisted instruction offered at the physician's office,'' Wunderlich said.

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