Article

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Malnutrition at Age 3 Years and Externalizing Behavior

Problems at Ages 8, 11, and 17 Years

Jianghong Liu, Ph.D.

Adrian Raine, D.Phil.

Peter H. Venables, Ph.D., D.Sc.

Sarnoff A. Mednick, Ph.D.,

Objective: Poor nutrition is thought to predispose to externalizing behavior problems, but to date there appear to have been no prospective longitudinal studies testing this hypothesis. This study assessed whether 1) poor nutrition at age 3 years predisposes to antisocial behavior at ages 8, 11, and 17 years, 2) such relationships are independent of psychosocial adversity, and 3) IQ mediates the relationship between nutrition and externalizing behavior problems.

Method: The participants were drawn from a birth cohort (N=1,795) in whom signs of malnutrition were assessed at age 3 years, cognitive measures were assessed at ages 3 and 11 years, and antisocial, aggressive, and hyperactive behavior was assessed at ages 8, 11, and 17 years.

Results: In relation to comparison subjects (N=1,206), the children with malnutrition signs at age 3 years (N=353) were more aggressive or hyperactive at age 8 years, had more externalizing problems at age 11, and had greater conduct disorder and excessive motor activity at age 17. The results were independent of psychosocial adversity and were not moderated by gender. There was a dose-response relationship between degree of malnutrition and degree of externalizing behavior at ages 8 and 17. Low IQ mediated the link between malnutrition and externalizing behavior at ages 8 and 11.

Conclusions: These results indicate that malnutrition predisposes to neurocognitive deficits, which in turn predispose to persistent externalizing behavior problems throughout childhood and adolescence.  The findings suggest that reducing early malnutrition may help reduce later antisocial and aggressive behavior.

(Am J Psychiatry 2004; 161:2005–2013)

Despite decades of research into social and biological

risk factors for childhood aggression, surprisingly little is

known about the role of malnutrition in contributing to

the development of childhood externalizing behavior (1,

2). Although deficiency in nutrition has been rarely studied

in relation to externalizing behavior, several studies

have demonstrated the effects of related factors, including

food additives, hypoglycemia, and, more recently, cholesterol

(2–4), on human behavior. In addition, epidemiological

studies have shown associations between increased

aggressive behavior and vitamin and mineral deficiency

(5, 6). Several authors have also claimed links between

iron-deficient anemia or low zinc level and externalizing

behavior in childhood (7, 8). More recently, the male offspring

of nutritionally deprived pregnant women were

found to have 2.5 times the normal rate of antisocial personality

disorder in adulthood (9). Effects were found for

severe malnutrition during the first and second trimesters

of pregnancy, but not the third trimester. Despite these

findings, the research literature on malnutrition and externalizing

behavior problems remains both limited and

controversial (2, 10).

If malnutrition is linked to antisocial behavior, as some

suggest, a key question concerns the mechanism of action.

One possible, but so far untested, hypothesis is that early

malnutrition predisposes to antisocial behavior because

malnutrition impairs neurocognitive functioning, which in

turn predisposes to externalizing behavior problems. There

is now compelling evidence that externalizing behavior

problems are characterized by lower IQ (11–14), and furthermore,

there is evidence that these early neurocognitive

deficits predict the onset of antisocial behavior (1, 15, 16).

In addition, there is increasing evidence that malnutrition

predisposes to lower IQ (17, 18). We recently observed that

malnutrition at age 3 was related to lower IQ at age 3 and

age 11 in a large longitudinal study in Mauritius (19), while

similar findings have also been observed by others (17, 20).

Despite the plausibility of the malnutrition-externalizing

hypothesis, we know of no empirical tests of it to date.

Research on nutrition and antisocial behavior has five

important limitations. First, there are simply very few

studies that have assessed the relationship between nutritional

deficits and externalizing behavior. Second, with

the exception of the prenatal study by Neugebauer et al.

(9), studies have not investigated prospectively the effect

of early nutrition on later aggressive behavior; it is possible,

for example, that antisocial behavior in the child could

produce parental neglect and malnutrition, rather than

vice versa. Third, there have been few, if any, studies on the

relation between nutritional deficits and aggression in fe2006

Am J Psychiatry 161:11, November 2004

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males as well as males. Fourth, to our knowledge, the possibility

of mediating mechanisms, such as neurocognitive

deficits, have not been tested. Fifth, prior studies have

rarely controlled for the confounding effects of psychosocial

adversity.

In this study we used longitudinal data from Mauritius

in order to begin to address these gaps in the literature by

testing the following hypotheses: 1) poor nutrition at age 3

years predisposes to antisocial behavior at ages 8, 11, and

17 years, 2) such relationships are independent of early

psychosocial adversity, and 3) IQ mediates the nutritionantisocial

relationship. If controlling for childhood intelligence

abolishes the relationship between early malnutrition

and later externalizing behavior problems, this would

provide evidence for the role of intelligence as a significant

mediating mechanism (21).

Method

Participants

Participants were drawn from a birth cohort of 1,795 children

from the island of Mauritius, which lies off the coast of Africa. On

the basis of vaccination records, all children born in 1969 and 1970

in two main towns on the island were recruited into the study between

September 1972 and August 1973 when they were 3 years

old. The two towns (Vacoas and Quatre Bornes) were chosen because

they were representative of the ethnic distribution of the

whole island. The sample consisted of both boys (51.4%) and girls

(48.6%). The ethnic distribution was as follows: Indian, 68.7%;

Creole (African origin), 25.7%; and other (Chinese, English, and

French), 5.6%. Census data for the island as a whole indicated 66%

Indian, 29% Creole, and 5% other, indicating that the study largely

achieved its goal of representing the ethnicity of the population. In

keeping with previous work on this population (14, 22), the data

analyses were restricted to Indians and Creoles because of the

small number of subjects in the “other” ethnic category. Oral informed

consent was obtained from the mothers of the participants

in the early phases and from the participants themselves in

the age 17 phase. Early research activities were conducted according

to the principles outlined in the Declaration of Helsinki (23),

which prevailed in 1972, when the research was initiated, while research

activities in later years were conducted according to principles

outlined in the Belmont Report (24). Institutional review

board approval for the later research phases and retrospective

data analyses was obtained from the University of Southern California

and from the University of California, Los Angeles.

Signs of Malnutrition at Age 3

At age 3 years, four early signs of malnutrition (19) were assessed

in a clinical examination of 1,559 of the children. Assessments

of the children were conducted with a structured protocol

by local pediatricians who had received their medical training in

Europe. All assessments were conducted at the research unit. The

four signs were as follows:

Angular stomatitis. Cracking in the lips and corners of the

mouth is predominantly a sign of riboflavin deficiency (vitamin

B2) but also reflects niacin deficiency (25, p. 97). The base rate for

angular stomatitis in the sample was 7.0%.

Hair dyspigmentation. This condition reflects protein malnutrition

(26) and is found in tropical regions, particularly in Africa

(26), where children’s hair takes on a reddish-orange color. The

base rate for red hair in the sample was 6.8%.

Sparse, thin hair. This indicator is a sign of protein-energy

malnutrition in particular (27, 28) and malnutrition in general

(29). Protein reduction impairs hair growth, while zinc and iron

deficiency can also lead to thin hair. The base rate for this symptom

in the sample was 5.8%.

Anemia. Anemia was indicated by a low hemoglobin level,

which reflects iron deficiency. Hemoglobin level was assessed

from a laboratory test of blood drawn from the child. Anemia was

defined as a hemoglobin level below 8.5 g/dl. This definition of

anemia was consistent with medical practice in Mauritius in the

early 1970s. The base rate in this sample was 17.0%.

Definition of malnutrition. A participant was defined as suffering

from nutritional deficits if at least one of the four preceding

indicators was present; 22.6% of the assessed children met this

definition. A participant with no indicator present was classified

as having relatively normative nutrition; 77.4% fit this category.

To assess for a dose-response relationship between malnutrition

and externalizing behavior, each subject for whom behavior data

were available was categorized into one of four groups: no malnutrition

(N=766 at age 8, N=807 at age 11, N=422 at age 17), one indicator

of malnutrition (N=160 at age 8, N=172 at age 11, N=90 at

age 17), two indicators (N=45 at age 8, N=50 at age 11, N=25 at age

17), or three indicators (N=10 at age 8, N=13 at age 11, N=4 at age

17). Because only two individuals had all four nutrition indicators,

this category could not be included in the dose-response

analyses. Children thought to have potentially significant medical

problems of any kind (including malnutrition, scabies, and parasitic

worm) were referred to appropriate agencies for treatment

(30), but neither these referrals nor the treatment outcomes were

recorded or coded.

Intelligence and Cognitive Ability at Ages 3 and 11

Age 3. Measures of total cognitive ability were derived from six

subtests of the Boehm Test of Basic Concepts—Preschool Version

(14, 31, 32), which assesses basic verbal and visual-spatial concepts

that are fundamental for early school achievement. Full details

of measurement, factor structure, reliability, and validity in

this sample are given elsewhere (14, 31). Data were available for

1,260 subjects.

Age 11. Estimates of full-scale IQ were assessed at age 11 years

by using seven subtests of the WISC (33). The similarities and

digit span subtests were used to form an estimate of verbal IQ,

while the block design, object assembly, coding, mazes, and picture

completion subtests were used to form an estimate of performance

IQ. Data were available on 1,260 subjects for the preceding

three measures.

Psychosocial Adversity at Ages 3 and 11

The age 3 index of psychosocial adversity (14, 22) was based on

nine psychosocial variables assessed by social workers who visited

the homes of the children at age 3 years (see reference 34 for

full details). The index was created along lines similar to those described

by Rutter (35) and Moffitt (36). A total adversity score was

created by adding one point for each of the following nine variables:

father uneducated, mother uneducated, semiskilled or unskilled

parental occupation, single parent status, separation from

parents, large family size, poor health of mother, teenage mother,

and overcrowded home. Complete data for this construct were

available for 1,795 participants.

The age 11 psychosocial adversity index (14, 19, 22) was based

on 14 variables assessed by social workers who visited the homes

of the children at age 11 years. A total adversity score was created

by adding one point for each of the following 14 variables: living

in rented accommodation, house without electricity or water,

child with neither good toys nor good books, no television, poor

housing, father uneducated, mother uneducated, parent psychiAm

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atrically ill, parent physically ill, teenage mother (age 19 or

younger when child was born), single parent status, separation

from both parents, five or more siblings, and overcrowded home

(five or more family members per room). Complete data were

available on 1,272.

Externalizing Behavior Problems

Age 8. Externalizing behavior was assessed by teacher ratings

with the Children’s Behavior Questionnaire (37); see earlier reports

(14, 22, 38) for full details of reliability and validity. Briefly, a

factor analysis of this scale produced a factor of “aggression-hyperactivity”

(38), with the four-item aggression scale having an

internal reliability (coefficient alpha) of 0.79 and the six-item hyperactivity

scale having a reliability of 0.64. Complete data were

available for 1,130 participants on the aggression measure and for

1,128 on the hyperactivity measure.

Age 11. Externalizing behavior was assessed from parental ratings

using the three externalizing subscales (aggression, delinquency,

hyperactivity) of the Child Behavior Checklist (39), with

item content common across boys and girls (22). The internal reliability

values (coefficient alpha) for the scales were as follows: 0.72

for aggression, 0.66 for delinquency, 0.57 for hyperactivity, and 0.84

for total externalizing problems. Construct validity data are provided

elsewhere (22, 34). Data were available for 1,206 children.

Age 17. Externalizing behavior was assessed by parent and

teacher ratings using the Revised Behavior Problem Checklist

(40); full details of reliability and validity have presented elsewhere

(14, 22). All four checklist subscales that reflect externalizing

behavior problems were included in the analyses: conduct

disorder, socialized aggression, excessive motor activity, and attention

problems. Complete data were available for 608 subjects.

Representativeness of Groups

Complete data on both the malnutrition and externalizing behavior

variables were available on 982 subjects at age 8, 1,044 at age

11, and 541 at age 17. Those with and without complete data at

each age were compared on gender and ethnicity, variables that

were available on all subjects at age 3. Results of these analyses are

shown in Table 1. There was a statistically significant overrepresentation

of Indians at all ages among the participants with complete

data and an overrepresentation of boys at age 11. Consequently,

ethnicity and gender were entered into the subsequent analyses in

order to assess their roles as moderator effects or confounds.

Statistical Analyses

In the comparisons of the malnourished and normal groups,

separate analyses were conducted for each of the three ages (8, 11,

and 17 years). To test for overall effects of malnutrition on externalizing

behavior problems, we conducted a multivariate analysis

of variance (MANOVA) on all dependent variables for each age

(e.g., hyperactivity, aggression, and delinquency at age 11). Univariate

F tests were then used to assess which specific subcomponents

of externalizing behavior were associated with malnutrition.

IQ and social adversity at ages 3 and 11 were identified as

potential mediators, i.e., variables accounting for a significant

portion of the relationship between the predictor (malnutrition)

and the outcome variable (externalizing behavior) (21). To test for

the mediating effects of cognition and psychosocial adversity,

these variables were each entered separately as covariates in the

MANOVAs. Gender and ethnicity were identified as potential

moderators, i.e., factors that may reduce or enhance the influence

of malnutrition on externalizing behavior, as indicated by an interaction

between the independent variable (malnutrition) and a

factor (gender, ethnicity) (21). To assess for moderating effects of

gender and ethnicity, we entered these variables as factors in the

MANOVA alongside the nutrition grouping. Any interactions were

broken down by stratifying on the moderator variable and conducting

two-way MANOVAs to test for simple interactions (41).

These in turn were broken down by tests of simple main effects.

To test for a dose-response relationship between degree of malnutrition

and degree of externalizing behavior problems, we constructed

four levels of the grouping factor (none, one, two, and

three malnutrition indicators), repeated the preceding MANOVAs

and univariate ANOVAs, and conducted tests for linear trends to

assess for a linear fit between degree of malnutrition and degree

of externalizing behavior. Two-tailed tests of significance with an

alpha set at 0.05 were used throughout.

Results

Detailed results of both the multivariate and univariate

F tests of the effects of malnutrition on externalizing behavior

at all three ages, including moderator and mediator

effects, are shown in Table 2.

Externalizing Behavior Problems at Age 8

Effect of malnutrition. A MANOVA on the two dependent

variables (aggression and hyperactivity) indicated a

main group effect (Table 2), demonstrating that the malnourished

children had higher overall externalizing behavior

scores. Univariate F tests indicated that the malnourished

group had significantly higher scores on both

hyperactivity and aggression (Figure 1, Table 2).

Mediators. The malnourished children were more likely

to have lower cognitive ability at age 3 than the normal

children and were more likely to suffer psychosocial adversity

at age 3 than the normal children (Table 3). Consequently,

it is possible that poor cognition or greater

psychosocial adversity could mediate the main effect of

malnutrition on externalizing behavior. This possibility

was tested by entering cognitive and adversity measures

separately as covariates in the preceding MANOVA.

The main effect of malnutrition was abolished after we

controlled for cognitive ability, indicating that cognitive

ability mediates the link between malnutrition and externalizing

behavior. In contrast, after we controlled for age 3

psychosocial adversity, the main effect of malnutrition remained

significant (Table 2), indicating that the relation-

TABLE 1. Ethnicity and Gender of Subjects With and Without

Complete Follow-Up Data Among 1,559 Children in

Mauritius Whose Nutritional Status Was Assessed at Age 3

Age at Follow-Up,

Ethnicity,

and Gender

Percent With Indian Ethnicity

or Male Gendera Analysis

Subjects With

Complete Data

Subjects With

Missing Data

÷2

(df=1) p

Age 8

Indian ethnicity 74.5 67.6 9.98 0.002

Male gender 51.2 52.5 0.30 0.59

Age 11

Indian ethnicity 74.6 66.9 12.37 0.001

Male gender 54.1 48.7 5.11 0.03

Age 17

Indian ethnicity 76.4 69.2 9.32 0.002

Male gender 53.1 51.2 0.55 0.46

a Percentages are based on the number of subjects at each follow-up

with complete or missing data.

2008 Am J Psychiatry 161:11, November 2004

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ship between malnutrition and externalizing behavior

was independent of psychosocial adversity.

Creoles were more likely to be malnourished than Indians

(Table 3). After we controlled for ethnicity by entering

it as a covariate, the effect of malnutrition on externalizing

behavior remained significant (Table 2).

Moderators. There were no interactions between nutrition

grouping and gender. However, there was a significant

interaction between ethnicity and nutrition grouping. In

order to clarify this two-way interaction, the sample was

stratified by race and one-way MANOVAs were conducted

separately on Creoles and Indians. The multivariate results

indicated that in both groups, malnutrition was significantly

associated with externalizing problems. For Creoles

there was a significant effect of malnutrition on externalizing

behavior (F=3.67, df=2, 236, p<0.03). Univariate F tests

indicated that malnourished Creoles had significantly

higher scores than normal Creoles on aggression (F=7.37,

TABLE 2. Results of Multivariate and Univariate Tests of the Effect of Malnutrition at Age 3 on Externalizing Behavior at

Ages 8, 11, and 17 Among Children in Mauritius

Age at Follow-Up, Type of Analysis,

and Behavior Variablea

Moderator Effects

Main Effect of Malnutrition

Gender-by-Malnutrition

Interaction

Race-by-Malnutrition

Interaction

N F df p F df p F df p

Age 8 982

Multivariate 5.63 2, 979 0.004 1.62 2, 975 0.24 3.47 2, 932 0.04

Univariate

Aggression 4.68 1, 980 0.04 1.63 2, 975 0.24 4.58 2, 933 0.04

Hyperactivity 11.28 1, 980 0.001 0.42 2, 976 0.52 0.06 2, 933 0.82

Age 11 1,044

Multivariate 4.18 3, 1042 0.006 1.19 3, 1037 0.31 1.50 3, 994 0.21

Univariate

Aggression 2.67 1, 1042 0.11 1.95 1, 1039 0.16 4.25 1, 996 0.04

Delinquency 2.10 1, 1042 0.15 0.18 1, 1039 0.67 3.22 1, 996 0.08

Hyperactivity 12.53 1, 1042 0.001 1.88 1, 1039 0.17 0.81 1, 996 0.37

Age 17 541

Multivariate 5.35 4, 536 0.001 1.34 4, 533 0.25 0.53 4, 514 0.72

Univariate

Conduct disorder 10.07 1, 539 0.002 0.12 1, 536 0.73 0.81 1, 517 0.37

Motor excess 6.11 1, 539 0.02 3.75 1, 536 0.053 0.12 1, 517 0.73

Attention problems 0.31 1, 539 0.58 0.50 1, 536 0.48 0.96 1, 517 0.06

Socialized aggression 0.63 1, 539 0.43 0.00 1, 536 0.98 0.01 1, 517 0.91

a At age 8, externalizing behavior was assessed with the Children’s Behavior Questionnaire. At age 11, externalizing behavior was assessed with

the Child Behavior Checklist. At age 17, externalizing behavior was assessed with the Revised Behavior Problem Checklist.

b Analyses of the follow-up at age 8 used the ratings of psychosocial adversity and cognitive ability at age 3. Analyses of the follow-ups at ages

11 and 17 used the ratings at age 11.

FIGURE 1. Scores for Externalizing Behaviors at Ages 8, 11, and 17 Among Children in Mauritius Who Were or Were Not

Malnourished at Age 3

a Number of subjects assessed at age 3.

4.0

3.0

2.0

1.0

3.5

2.5

1.5

0.5

0.0

Aggression Hyperactivity Aggression Hyperactivity Delinquency Conduct

disorder

Motor

excess

Attention

problems

Socialized

aggression

Score on Scale From Children’s

Behavior Questionnaire

Age 8 Age 11 Age 17

Comparison

subjects (N=1,206)a

Malnourished

children (N=353)a

6

4

2

5

3

1

0

Score on Scale From Child Behavior Checklist

12

8

6

4

2

10

11

9

7

5

3

1

0

Score on Scale From Revised

Problem Behavior Checklist

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df=1, 237, p<0.008), but the effect for hyperactivity was not

significant (F=2.92, df=1, 237, p=0.09). For Indians, there

was a significant effect of malnutrition on externalizing behavior

(F=3.43, df=2, 695, p<0.04), with higher scores for

externalizing behavior among the malnourished Indians

than among the normal Indians. Univariate F tests indicated

that malnourished Indians had significantly higher

scores than normal Indians on hyperactivity (F=4.85, df=1,

696, p<0.03), but the effect for aggression was not significant

(F=0.15, df=1, 696, p=0.70). Consequently, these analyses

indicate that malnutrition is more likely to predispose

Creole children to aggression at age 8 but predispose Indian

children to hyperactivity at age 8.

Externalizing Behavior Problems at Age 11

Effect of malnutrition. As shown in Table 2, the overall

MANOVA indicated a main effect of malnutrition on externalizing

behavior scores at age 11 years. The univariate F

tests showed a significant effect of malnutrition on hyperactivity

but not on aggression or delinquency (Figure 1).

Mediators. As shown in Table 3, the malnourished children

had lower cognitive ability at age 11 than the nonmalnourished

children. After we controlled for cognitive

ability, the main effect of nutritional status was abolished,

indicating a mediating effect of low cognitive ability. Although

the malnourished and comparison children did

not differ significantly on adverse psychosocial backgrounds

at age 11, the difference approached significance.

Consequently, to ensure that adversity did not mediate the

findings, the age 11 total psychosocial adversity score was

entered as a covariate in the preceding MANOVA. The

main group effect remained significant.

Moderators. Multivariate results indicated that there were

no significant moderator effects for gender at all ages and no

moderator effects for ethnicity at ages 11 and 17, although

ethnicity was a significant moderator at age 8 (Table 2).

Externalizing Behavior Problems at Age 17

Effect of malnutrition. A MANOVA conducted on conduct

disorder, motor excess, attention problems, and socialized

aggression showed a significant overall main effect

of malnutrition (Table 2). Univariate F tests showed that

the malnourished group had significantly higher scores on

conduct disorder and motor excess but not on attention

problems or socialized aggression (Figure 1, Table 2).

Mediators. After age 11 cognitive ability was entered as a

covariate, the main effect of malnutrition remained significant.

The main group effect also remained significant after

we controlled for age 11 psychosocial adversity (Table 2).

Moderators. There was no significant moderator effect

for gender or ethnicity (Table 2).

Dose-Response Relationships

Dose-response relationships between malnutrition and

externalizing behavior are depicted in Figure 2. MANOVAs

indicated a significant main effect of the degree of malnutrition

on externalizing behavior at age 8 (F=2.53, df=6,

1954, p=0.02), and the linear term was also significant for

both aggression (F=5.92, df=1, 977, p<0.02) and hyperactivity

(F=11.96, df=1, 977, p<0.001). At age 17, there was

also a main effect of the degree of malnutrition (F=2.44,

df=12, 1608, p<0.004) and significant linear trends for conduct

disorder (F=10.14, df=1, 537, p<0.002) and motor excess

(F=8.58, df=1, 537, p<0.004). For age 11, the main effect

of nutrition was nonsignificant (F=1.84, df=9, 3114, p=

0.06), although the linear term was significant for hyperactivity

(F=9.19, df=1, 1038, p<0.002). Univariate F tests

showed significant group differences for age 8 hyperactivity

(F=4.60, df=3, 977, p<0.003), age 11 hyperactivity (F=

4.36, df=3, 1038, p<0.005), age 17 conduct disorder (F=

3.53, df=3, 537, p<0.02), and age 17 motor excess (F=2.95,

df=3, 537, p<0.04). The results of all other univariate tests

(i.e., on aggression at age 8, aggression and delinquency at

age 11, and attention problems and socialized aggression

at age 17) were nonsignificant (p>0.11).

In order to assess whether poor cognition mediated the

preceding dose-response relationships, the tests were repeated

after we entered the cognitive measures as covariates.

All effects of nutrition were abolished (age 8: F=1.14,

df=6, 1488, p=0.34; age 17: F=1.69, df=12, 1401, p=0.07), indicating

a mediating role of poor neurocognitive functioning.

Discussion

Key Findings

One key finding of this study is that malnutrition at age

3 years is associated with higher scores for externalizing

behavior problems at ages 8, 11, and 17. A second key find-

Mediator Effects

Psychosocial Adversity

at Age 3 or 11b

Cognitive Ability

at Age 3 or 11b

F df p F df p

4.49 2, 976 0.02 1.58 2, 746 0.21

4.05 1, 977 0.05 1.37 1, 747 0.24

8.97 1, 977 0.003 3.15 1, 747 0.08

4.04 3, 1002 0.007 1.40 3, 973 0.24

2.84 1, 1004 0.10 1.32 1, 975 0.25

2.32 1, 1004 0.13 0.35 1, 975 0.55

12.14 1, 1004 0.001 3.79 1, 975 0.05

3.91 4, 480 0.004 3.69 4, 467 0.006

5.59 1, 483 0.02 4.45 1, 470 0.21

3.55 1, 483 0.06 1.25 1, 470 0.26

0.53 1, 483 0.47 1.16 1, 470 0.28

1.56 1, 483 0.21 1.64 1, 469 0.20

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ing is that the relationship between malnutrition and externalizing

behavior was not found to be an artifact of psychosocial

adversity but was instead mediated by cognitive

ability, indicating that malnutrition predisposes children

to a lower IQ, which in turn predisposes them to externalizing

behavior problems. These conclusions are supported

by the finding of dose-response relationships between degree

of malnutrition and degree of externalizing behavior

problems at ages 8 and 17, relationships that were again

found to be mediated by low IQ. To our knowledge, these

are the first findings to show prospectively that malnutrition

assessed in the early postnatal years is associated with

externalizing behavior problems from childhood to late

adolescence and also to show the mediating effects of cognitive

ability. These findings in turn have potential implications

for public health attempts to prevent the occurrence

of externalizing behavior problems in children and

adolescents.

The robustness of the findings is indicated in several

ways. First, malnutrition predisposed to externalizing behavior

problems across several ages from childhood (age

to late adolescence (age 17). Second, externalizing behavior

problems were measured by three different instruments

at the three different ages, indicating that the findings were

replicated across sources and were largely invariant to the

nature of measurement (42). Third, the fact that gender

and ethnicity did not moderate the multivariate findings at

ages 11 and 17 indicates that the nutrition-externalizing relationship

is not specific to one gender or ethnic grouping,

although it should be noted that at age 8 malnutrition was

more likely to predispose to aggression in Creoles and to

hyperactivity in Indians. It is possible that malnutrition

predisposes to a general disinhibitory tendency and that

broad cultural differences influence the precise manifestations

of such disinhibition at a behavioral level. Fourth, the

fact that dose-response relationships were found at ages 8

and 17 confirms and extends the findings based on comparisons

of the malnourished and nonmalnourished children,

although it is noted that the dose-response effect at

age 11 was not statistically significant (p=0.06). For these

reasons, we believe that the findings cannot be easily attributed

to chance and that, instead, they reflect a reliable

relationship between early malnutrition and later externalizing

behavior problems.

TABLE 3. Demographic and Cognitive Measures at Ages 8, 11, and 17 Among Children in Mauritius Who Were or Were Not

Malnourished at Age 3

Age at Follow-Up

and Variable

Malnourished Not Malnourished

Percent of Ethnic

or Gender Group Mean SD N

Percent of Ethnic

or Gender Group Mean SD

Analysis

N ÷2 t df p

Age 8 216 766

Ethnicity 7.67 1 0.006

Creole 28.0 72.0

Indian 19.5 80.5

Gender 0.82 1 0.40

Male 23.1 76.9

Female 20.7 79.3

Psychosocial adversity

score at age 3a 2.21 1.35 1.83 1.31 3.80 978 0.001

Cognitive ability score

at age 3b 96.51 14.20 100.44 15.25 2.84 748 0.005

Age 11 1,044 762

Ethnicity 0.45 1 0.54

Creole 24.0 76.0

Indian 22.0 78.0

Gender 0.10 1 0.78

Male 22.3 77.7

Female 23.2 76.8

Psychosocial adversity

score at age 11c 2.02 1.49 1.80 1.52 1.87 1005 0.07

Cognitive ability score

(IQ) at age 11 95.88 15.58 101.27 14.36 4.80 976 0.001

Age 17 541 1,265

Ethnicity 0.07 1 0.80

Creole 22.8 77.2

Indian 21.6 78.4

Gender 0.13 1 0.76

Male 22.3 77.7

Female 23.2 76.8

Psychosocial adversity

score at age 11 2.13 1.52 1.87 1.54 1.55 484 0.12

Cognitive ability score

(IQ) at age 11 94.37 16.57 99.46 15.56 2.92 471 0.004

a Range=0–9; 9=greatest severity.

b Higher scores indicate greater cognitive ability.

c Range=0–14; 14=greatest severity.

Am J Psychiatry 161:11, November 2004 2011

LIU, RAINE, VENABLES, ET AL.

http://ajp.psychiatryonline.org

Nutrition, Brain Development,

and Externalizing Behavior

A critical question concerns the mechanism by which

malnutrition predisposes to later externalizing behavior

problems. We hypothesize that early malnutrition negatively

affects brain growth and development and that

brain impairments predispose to antisocial and violent

behavior by affecting cognitive functions. The indicators

of malnutrition in this study reflect deficits in protein (red

hair, sparse/thin hair), iron (low hemoglobin level), and

zinc (red hair, sparse/thin hair). There is extensive experimental

evidence in animals both that zinc and protein deficiency

impairs brain development (8, 43–45) and that

protein, iron, and zinc deficiency predisposes to aggression

(45–47). In humans, zinc deficiency during pregnancy

has been linked to impaired DNA, RNA, and protein synthesis

during brain development as well congenital brain

abnormalities (48). There is also evidence in humans that

antisocial behavior is related to protein deficiency (9) and

iron-deficient anemia (7). Consequently, protein, iron,

and zinc deficiencies may contribute to the brain impairments

that have been found in aggressive adult offenders

and that in turn are thought to predispose to aggressive

antisocial behavior (3, 15, 46, 49).

While early malnutrition could thus relatively directly predispose

to externalizing behavior problems by impairing

brain mechanisms such as those in the prefrontal cortex

that are thought to regulate emotion and inhibit impulsive

aggressive behavior (for example, see reference 50), malnutrition

could also predispose to externalizing behavior problems

more indirectly by impairing cognitive functioning,

which in turn predisposes to externalizing behavior problems.

The findings from the present study provide partial

(but not total) support for this possibility. Cognitive functioning

was established as a mediator for the malnutritionexternalizing

relationship at ages 8 and 11 years in that controlling

for the effect of IQ on externalizing behavior abolished

the malnutrition-externalizing relationship. Poor cognitive

ability has been found consistently to predispose to

externalizing behavior problems (51). Nevertheless, support

for this cognitive explanation of the malnutrition-externalizing

relationship is not entirely complete. While mediating

effects were observed at ages 8 and 11 and while poor cognition

mediated the dose-response relationship at age 17, it

did not mediate overall differences between the malnourished

and comparison groups in age 17 externalizing behavior,

possibly because of the 6-year gap between the assessments

of IQ (age 11) and externalizing behavior (age 17).

Clinical Implications and Limitations

Externalizing behavior problems are important predisposing

factors in later adult violent offenses (52), and violence

prevention and protection from victimization have

become two of the most pressing issues facing society today

(52, 53). One recent double-blind, placebo-controlled,

randomized experimental trial showed that supplementation

of adult prisoners’ diet with vitamins, minerals, and

essential fatty acids significantly reduced antisocial and

violent behavior in prison (54). Although dietary interventions

for adults may prove helpful in reducing antisocial

and violent behavior, identification of early risk factors for

childhood and adolescent aggression is a critically important

first step for developing successful prevention

programs for such adult violence. Because nutrition is a

FIGURE 2. Dose-Response Relationships Between Number of Malnutrition Indicators at Age 3 and Externalizing Behaviors

at Ages 8, 11, and 17 Among Children in Mauritiusa

a Four indicators of malnutrition were assessed: angular stomatitis, hair dyspigmentation, sparse/thin hair, and anemia.

4.0

2.0

1.0

1.5

0.5

3.5

2.5

3.0

0.0

Score on Scale From Children’s

Behavior Questionnaire

Age 8 (N=982) Age 11 (N=1,044) Age 17 (N=541)

12

11

10

8

6

4

2

9

7

5

3

1

0

Score on Scale From Revised

Problem Behavior Checklist

0 1 2 3 0 1 2

Number of Malnutrition Indicators

3 0 1 2 3

6

4

2

5

3

1

0

Score on Scale From Child Behavior Checklist

Motor excess

Conduct disorder

Delinquency

Hyperactivity

Aggression

2012 Am J Psychiatry 161:11, November 2004

MALNUTRITION AND EXTERNALIZING BEHAVIOR

http://ajp.psychiatryonline.org

malleable factor, it may be more practical and easier to

prevent externalizing behavior through better early nutrition

targeting at-risk populations than more complex and

expensive psychosocial manipulations. The fact that several

studies that have included the promotion of early nutrition

as part of a larger prevention program have met

with success (55, 56) argues for further attention to early

malnutrition as a predisposing factor in externalizing behavior

among children. It is possible, however, that malnutrition

at age 3 years is correlated with poor prenatal

malnutrition and that prenatal, rather than postnatal, interventions

for malnutrition may be most effective (9, 55).

Finally, three potential limitations of the study should

be acknowledged. First, the findings suggest but do not

prove that early malnutrition predisposes to later externalizing

behavior. Randomized, controlled designs that

manipulate nutritional intake and evaluate diet in children

are needed to support the role of nutrition as an etiological

factor in externalizing behavior. Nevertheless, the

fact that interventions that indirectly manipulate nutrition

have been found to reduce later conduct disorder (55,

56) suggests that a possible etiological role of malnutrition

in externalizing behavior should not be discounted. Second,

because nutrition was assessed at only one time

point (age 3 years) this study could not ascertain whether

the effects on externalizing behavior were produced by

transient malnutrition (i.e., the first 3 years only), by more

sustained malnutrition, extending beyond the third year,

or by maternal malnutrition during pregnancy (9). Third,

there are cultural, ethnic, and social differences between

Mauritius and the United States that highlight the importance

of replicating the present findings in Europe and the

United States. Nevertheless, the current findings from

Mauritius may be a good model for externalizing problems

in underserved subpopulations of American society,

particularly since food insufficiency is relatively common

in poor rural areas of the United States and has been associated

with poor behavioral functioning in low-income

children in American inner cities (57, 58).

Received June 10, 2003; revision received Dec. 2, 2003; accepted

Jan. 19, 2004. From the Social Science Research Institute and the Department

of Psychology, University of Southern California; and the Department

of Psychology, University of York, York, U.K. Address reprint

requests to Dr. Raine, Department of Psychology, University of Southern

California, Los Angeles, CA 90089-1061; raine@usc.edu (e-mail).

Supported by a predoctoral fellowship award (F31 NR-07518) and

postdoctoral fellowship (F32 NR-08661) from the National Institute of

Nursing Research to Dr. Liu; an NIMH Independent Scientist Award

(K02 MH-01114), a grant from the Borchard Foundation, and a grant

from NIMH (RO1 MH-46435) to Dr. Raine; grants from the Medical Research

Council, Leverhulme Trust, and Mental Health Foundation to

Dr. Venables; an NIMH Research Scientist Award to Dr. Mednick (5

K05 MH-00619); and a grant from the Ministry of Health of the Mauritian

government.

The authors thank Marie-Clare Calambay, Meena Calinghen,

Athene Chiriaca, Cyril Dalais, Fazila Dinally, Devi Jaganathen, Goorah

Rajah, and Charles Yip Tong for help in data collection and scoring.

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Harmful pesticides found in everyday food products
By Andrew Schneider
Seattlepi, 1/30/2008 

Read full study here

Government promises to rid the nation’s food supply of brain-damaging pesticides aren’t doing the job, according to the results of a yearlong study that carefully monitored the diets of a group of local children.

The peer-reviewed study found that the urine and saliva of children eating a variety of conventional foods from area groceries contained biological markers of organophosphates, the family of pesticides spawned by the creation of nerve gas agents in World War II.

When the same children ate organic fruits, vegetables and juices, signs of pesticides were not found.

“The transformation is extremely rapid,” said Chensheng Lu, the principal author of the study published online in the current issue of Environmental Health Perspectives.

“Once you switch from conventional food to organic, the pesticides (malathion and chlorpyrifos) that we can measure in the urine disappears. The level returns immediately when you go back to the conventional diets,” said Lu, a professor at Emory University’s School of Public Health and a leading authority on pesticides and children.

Within eight to 36 hours of the children switching to organic food, the pesticides were no longer detected in the testing.

The subjects for his testing were 21 children, ages 3 to 11, from two elementary schools and a Montessori preschool on Mercer Island.

The community has double the median national income, but the wealth of Mercer Island made no difference in the outcome, he said.

“We are confident that if we did the same study in poor communities, we would get the same results,” he said. The study is being repeated in Georgia.

The study has not yet linked the pesticide levels to specific foods, but other studies have shown peaches, apples, sweet bell peppers, nectarines, strawberries and cherries are among those that most frequently have detectable levels of pesticides.

Measuring the harm

Lu is quick to point out that there is no certainty that the pesticides measured in this group of children would cause any adverse health outcomes. However, he added that a recent animal study demonstrated that persistent cognitive impairment occurred in rats after chronic dietary exposure to chlorpyrifos.

Death or serious health problems have been documented in thousands of cases in which there were high-level exposures to malathion and chlorpyrifos. But a link between neurological impairments and repeated low-level exposure is far more difficult to determine.

“There’s a large underpinning of animal research for organophosphate pesticides, and particularly for chlorpyrifos, that points to bad outcomes in terms of effects on brain development and behavior,” Dr. Theodore Slotkin, a professor of pharmacology and cancer biology at Duke University in North Carolina, said in the April 2006 Environmental Health Perspectives.

Lu says more research must be done into the harm these pesticides may do to children, even at the low levels found on food.

“In animal and a few human studies, we know chlorpyrifos inhibits an enzyme that transmits a signal in the brain so the body can function properly. Unfortunately, that’s all we know.”

Not many chemicals, including pharmaceutical products, were designed specifically to kill mammals, which was genesis of organophosphates.

“It is appropriate to assume that if we — human beings — are exposed to (this class of) pesticides, even though it’s a low-level exposure on a daily basis, there are going to be some health concerns down the road,” said Lu, who is on the Environmental Protection Agency’s pesticide advisory panel.

The EPA says it eliminated the use of organophosphates on many crops and imposed numerous restrictions on the remaining organophosphate pesticide uses.

Congressional concern that children were being harmed by excessive exposure to pesticides led to the unanimous passage of the Food Quality Protection Act. At its heart was a requirement that by 2006, the EPA complete a comprehensive reassessment of the 9,721 pesticides permitted for use and determine the safe level of pesticide residues permitted for all food products.

“As a result, the amount of these pesticides used on kids’ foods (has undergone) a 57 percent reduction,” said Jonathan Shradar, the EPA’s spokesman.

But that’s not nearly enough to prevent birth defects and neurological problems, said Chuck Benbrook, chief scientist of the Organic Center, a nationwide, nonprofit, food research organization.

“The pesticide limits that EPA permits are far, far too high to say they’re safe. And, the reduction that EPA cites in the U.S. has been accompanied by a steady increase in pesticide-contaminated imported foods, which are capturing a growing share of the market,” he said.

Yet the EPA continues to insist that “dietary exposures from eating food crops treated with chlorpyrifos are below the level of concern for the entire U.S. population, including infants and children.”

That statement is “not supported by science,” Benbrook said.

“Given the almost daily reminders that children are suffering from an array of behavioral, learning, neurological problems, doesn’t it make sense to eliminate exposures to chemicals known to trigger such outcomes like chlorpyrifos?” he asked.

What to do

While the gut reaction of some parents might be to limit the consumption of fresh produce or switch completely to organic food, Lu cautions not to make the wrong decision.

“It is vital for children to consume significantly more fresh fruits and vegetables than is commonly the case today,” he says, citing such problems as juvenile diabetes and obesity.

“Nor is our purpose to promote the consumption of organic food, although our data clearly demonstrate that food grown organically contains far less pesticide residues.”

Lu says an all-organic diet is not necessary. He has two sons, 10 and 13, and he estimates that about 60 percent of his family’s diet is organic.

“Consumers,” he says, “should be encouraged to buy produce direct from the farmers they know. These need not be just organic farmers, but conventional growers who minimize their use of pesticides.”

Understanding how fruits and vegetables grow can help guide the consumer, he says.

For example, organic strawberries probably are worth the money because they are a tender-fleshed fruit grown close to the dirt, so more pesticides are needed to fight insects and bugs from the soil. He adds apples and spinach to his list.

“It may also be money-smart to choose conventionally grown broccoli because it has a web of leaves surrounding the florets, resulting in lower levels of pesticide residue,” Lu says.

He is greatly concerned about one finding from the study.

“Overall pesticide (marker) levels in urine samples were even higher in the winter months, suggesting children may have consumed fruits and vegetables that are imported. The government needs to ensure that imported food comply with the standards we impose on domestic produce,” he said.

Dangerous science

Chlorpyrifos, made by Dow Chemical Co., is one of the most widely used organophosphate insecticides in the United States and, many believe, the world.

For years, millions of pounds of the chemical insecticide were used in schools, homes, day care centers and public housing, and studies show that children were often exposed to enormously high doses. Just as the EPA was ready to ban the product, which analysts said would have damaged Dow’s overseas sales, the company “voluntarily” removed it from the home market. Yet, with few exceptions, the agricultural uses continued.

The EPA’s Web site is a study in contradictions when it comes to chlorpyrifos.

At one section, it “acknowledged the special susceptibility and sensitivity of children to developmental and neurological effects from exposure to chlorpyrifos.”

But in another section, the agency reports that infants and children face no risk from eating food crops treated with chlorpyrifos. However, the agency doesn’t say how it reached that conclusion. There is no agreement of how much of the neurotoxin is too much.

Benbrook said the EPA has refused orders from Congress to study the cumulative developmental risk to children from low-dose exposures.

“Perhaps we can rest assured that EPA has protected us adults from acute insecticide poisoning risk, but our kids are on their own,” Benbrook said. 

From CopperWiki

 “Organic” refers to the growing and processing of agricultural products, such as fruits, vegetables, grains, dairy products and meat, in a way designed to encourage soil and water conservation and reduce pollution.

Why should I be aware of this?

Demand for organic food is growing for the last decade. There has been a 30 percent growth in the organic food market over the last 5-6 years because of strong public opinion that organic food is healthier than conventional food.

There have been more than a hundred studies about the benefits of organic over non- organic food. But all have so far been inconclusive. As a result official food agencies around the world are unanimous in claiming that there is no evidence of a nutritional difference. Even the FDA and the USDA clearly mention that non organic food is as healthy as organic food.

Though more research needs to be done, in a 2001 review of 41 studies, organic crops were all shown to have higher levels of Vitamin C, magnesium and phosphorus. Further studies in 2006 and 2007 have found higher levels of Vitamin C in organic fruit and 68 per cent higher levels of omega-3 in organic whole milk than non-organic whole milk. In October 2007, results of the EU-funded Quality Low Input Food Study indicated that organic fruit and vegetables contain 40 per cent more antioxidants than non-organic.

Organic food and health

The belief in the superiority of organic food over conventional food is primarily based on a recent research conducted on organic milk at the Danish Institute of Agricultural Research, University of Aberdeen, and the Institute of Grassland and Environmental Research. The findings showed that organic milk has more antioxidants, omega 3, CLA, and vitamins than non organic milk. The findings stated that organic milk is healthier than non organic milk as organic cows are pasture grazed and, therefore, give better quality milk.

These findings have increased the hopes that there would be a gradual shift from the use of chemical fertilizers and pesticides in numerous products to the more sustainable organic farming practices.

Concerns about pesticides

Consumers are greatly concerned that residual levels of pesticides in food are affecting all, especially kids, as they, unlike adults, have less ability to detoxify pesticides. It is accepted that pesticides in food can do the following:

• Cause low birth weight and birth defects;
• Interfere with child development and cognitive ability;
• Cause neurological problems;
• Disrupt hormone function;
• Cause a variety of cancers, including leukemia, kidney cancer, brain cancer, and non-Hodgkin’s lymphoma.

Food and environment

Environmental friendliness or benefits for the environment are a key concept of organic farming. As harmful chemicals are not used in organic farming, there is minimal soil, air and water pollution; thus ensuring a safe world for future generations to live in.

However, a team of student researchers in the Department of Rural Economy at the University of Alberta in Edmonton, Canada, showed transportation to great distances produces so much greenhouse gas emissions that it mitigates the environmental benefits of growing the food organically. The researchers found little difference in the food miles between conventionally produced and organic food items.

In another report the UK’s Department for Environment, Food and Rural Affairs (DEFRA), while admitting that the environmental effects of organic agriculture are lower than for the equivalent conventionally-grown food, felt it was not true for all foods “and appears seldom to be true for all classes of environmental effects.” The study did not find enough evidence to substantiate that organic agriculture has less environmental effect than conventional agriculture.

The report, titled “The Environmental Impact of Food Production and Consumption”, concludes that locally-sourced products are not necessarily more energy efficient than globally sourced products. The report also felt that reduced use of fertilizers required more, not less, land for agriculture, increased pressure on natural forests and ecosystems.

All about organic food

According to a study by the Journal of Agricultural and Food Chemistry, a peer-reviewed journal of the American Chemical Society, the world’s largest scientific society, (in its Feb. 26 print edition), fruits and vegetables grown organically are found to have significantly higher levels of cancer-fighting antioxidants than conventionally grown foods. Studies were done on corn, strawberries and marionberries.

The study suggested that while fertilizers in conventional food items boost the levels of anti-cancer compounds, pesticides and herbicides actually thwart the production of phenolics chemicals that act as a plant’s natural defense and are beneficial to our health.

Proponents of conventional food, however, claim that the levels of pesticides in food are of no threat to human health. But these safety levels are set for individual pesticides, but many samples of fresh produce carry multiple pesticide residues. This synergetic effect results in reproductive, immune and nervous system effects. This would not have happened in the case of individual compounds acting alone.
Israeli researchers have linked symptoms such as headaches, tremor, lack of energy, depression, anxiety, poor memory, dermatitis, convulsions, nausea, indigestion and diarrhea with dietary intakes of pesticides. Belgian research has found that women diagnosed with breast cancer are six to nine times more likely to have the pesticides DDT or hexachlorobenzene in their bloodstreams compared to women who did not have breast cancer. Hawaiian researchers following 8,000 people for 34 years have found that increasing consumption of conventional fruit and juice (and the pesticide residues they carry) raises the risk of Parkinson’s disease.

Dr. Vyvyan Howard, toxico-pathologist at the University of Liverpool, UK, comments on the trend towards organic food on the part of health-minded consumers:

“People are applying the precautionary principle to their own lives by purchasing food that has not been produced by industrial methods. From the simple stance of hazard avoidance, organically produced food is the best option that we have.”

The British Medical Association appears to agree: “Until we have a more complete understanding of pesticide toxicity, the benefit of the doubt should be awarded to protecting the environment, the worker, and the consumer — this precautionary approach is necessary because the data on risk to human health from exposure to pesticides are incomplete.”

Decline the mineral levels

Official food composition tables, including data compiled by the US Department of Agriculture, have been showing a substantial decline the mineral levels in fruits, vegetables, meat and dairy in conventional foods since the 1940s. This problem is compounded by earlier (pre-ripened) picking, longer storage, and more processing of crops.

Studies have shown that artificial fertilization of conventional crops produces lush growth by swelling the produce with more water. On a pound-for-pound basis, organic food has more “dry matter” (i.e. food). Partly because of this (and for other reasons too), there are higher levels of nutrients in organic produce. There are also evidences of higher phytonutrients, many of which are antioxidants involved in the plant’s own defense system, in organic produce because in the absence of regular applications of chemical pesticides, organic crops rely more on their own defenses.

A recent review of the subject estimated that organic produce will tend to contain 10-50% higher phytonutrients than conventional produce. Phytonutrients are certain organic components of plants, and these components are thought to promote human health. Fruits, vegetables, grains, legumes, nuts and teas are rich sources of phytonutrients.

Other evidences:

• Organic tomatoes have higher levels of lycopene – Lycopenes give tomatoes their red color. Tomatoes are one of the best sources for lycopene.
• Higher polyphenols in organic potatoes – Research indicates that polyphenols may have antioxidant characteristics with potential health benefits. They may reduce the risk of cardiovascular disease and cancer.
• There are higher flavonols in organic apples – Eating flavonol-rich foods like apples may help reduce the risk of pancreas cancer
• Higher resveratrol in organic red wine – Resveratrol in red wine has been shown to be beneficial to health by lowering cholesterol and preventing cell oxidation, an important process in the prevention of cancer.

Taste benefits

As it uses organic means of production, there is a strong belief that organic food tastes better than conventional food. Use of chemicals makes a number of produce draw more water out of the soil and become diluted in the process. This gives the end product a watered down taste. Scientists have been successful in developing organic farming techniques which increase the antioxidant contents of food. These compounds are generated by plants to protect themselves from pests and diseases. Stress events on plants such as insects or weeds can trigger the plant’s defense mechanisms. They respond by creating a range of phenolics, flavonoids, volatile compounds and other antioxidants.

 When we eat these aromatic compounds they give a heightened reception of flavor.

Soil Association, UK’s organic body, in a survey in 2005 found consumers prefer organic food because it tastes better as non-use of chemical pesticides, herbicides and fertilizers help keep toxins out of air, water and soil. Ninety-five percent of the respondents said they buy organic food as much to avoid pesticides and food additives as for the taste factor. Fruit and vegetable scored particularly high on taste, with 72 percent of the respondents claiming that they taste better than non-organic fruits.

Food safety

There is limited empirical evidence on the safety and relative risks of organic produce. Organically produced food has not been proved to be more or less safe than conventionally produced food. Organic certification does not require the grower to use production practices that eliminate, reduce or control the presence of pathogenic microorganisms, although some organic standards address microbiological food safety issues indirectly.

In the UK microbiological sampling of organic produce found only minor contamination using indicator organisms E. coli (in 0.5% of samples) and Aeromonas spp. (in 34% of samples). No comparative study was carried out on conventional produce, and hence, no conclusion could be reached.

A similar study in the US found same quantity of E. coli and salmonella spp.in both organic and conventional food.

Animal welfare

Organic Meat Organic farming reminds one of the good old days of traditional farming before the advent of animal factories. The growing fear of food-borne illnesses, Mad Cow disease, E.coli, salmonella, improper food handling, pesticides, antibiotics and hormones, and the threat of a contaminated water supply and other environmental disasters from gross over-concentration of animals in the meat industry, have forced consumers to look for new healthier options to feed their families.

Short of avoiding meat altogether, many people are discovering another facet of the world of organics: meats, poultry, dairy and eggs. As animals are grown organically they are naturally robust and hardly fall sick.

Certified organic meats are carefully scrutinized and tested for food safety and for strict compliance to the regulations at every step of the process.

Some of their guidelines are:

• No pesticides, antibiotics or hormones.
• 100% certified organic feed and pasture, which means no genetically modified foods seeds or feeds or and is raised without herbicides, pesticides or chemical fertilizers.
• No nitrates, nitrites or preservatives.
• Animals are never fed animal by-products
• Freedom of movement for animals, with full access to the outdoors. Humane treatment of animals (defined by the Humane Society of the United States.)
• Farm and farm records are inspected every year by a third party to ensure the standards are being enforced.

Why does organic food cost more?

Though some organic food is priced same as conventional food, they are often 25 %, 50% or even twice as expensive.

Agro-chemical agriculture is heavily subsidized by the governments while organic farming receives no subsidy. Farming subsidies are reported to be costing the UK taxpayer about £3 billion pounds every year

Agro-chemicals are designed to make food cheaper to produce as they were not developed with nutrition, taste or the ecology in mind. The objective always was mass production.

The yields of organic food are on average between 10 and 20% lower than in conventional agriculture and, with some crops (potatoes, for example), it may be as much as 40% lower.

Production costs are higher in organic farming. For example, organic farmers don’t use herbicides so they have to weed some crops, such as onions and carrots, by hand. This requires more people to be employed. Such a labor intensive method contributes to a more expensive product.

Animal welfare standards for organic food are very high. More land and more labor are needed to meet those standards.

Cows are grass-fed, so they need more land than grain-fed cows penned in a lot. The chickens eat organic grains and run free.

Cost of organic food certification is also very high. It is expensive to send someone to a farm and spend all day checking records.

Organic seeds are also very expensive.

Growth in the demand for organic food has also pushed up buying from local markets. A benefit of buying from local farmers is less fuel burned getting the goods to shoppers. It’s considered more sustainable economically, socially and environmentally.

Farmers markets give consumers a chance to talk with farmers — helping them learn about food production, identifying farmers selling organic items but without the certification and giving people a better understanding of why organic costs more.

According to a Morgan Stanley study, organic food can be up to 63 percent more expensive. But if local, seasonal food is bought directly from the producer, the premium can be lower.

Can people afford it?

More than the ability to afford is the question of attitude and the need to educate consumers.

In Australia and the UK official household spending statistics show that the average family spends five times more on junk food, take-away (carry-out food), alcohol, and tobacco than on fruits and vegetables, and five times more on recreation than on fruits and vegetables.

Switching to Organic Food

Over the years organic food has progressed from dry, boxed cereals or turkey bacon to include various types of food, including wine — or even caviar. A large number of parents are shifting to organic food to keep their children’s diets free of food grown with pesticides, hormones, antibiotics or Genetic Engineering.

Fast Growing Organic Products

Fresh fruit and vegetables — 40 percent of the market, 8.4 % annual growth.

Milk products, cereals, bread, convenience food, frozen food and baby food — 60 percent of the sales and growing at 36% annually.

http://www.publicbroadcasting.net/kunr/news.newsmain/article/0/0/1647855/Nevada.Newsline/Dietary.SupplementsBonnie

Used as body fuel by tissues of the brain, nervous system and muscle

Important in converting energy to stored energy in the body’s Kreb’s energy cycle

Glycogenic (energy storage source of glucose by the liver and muscles)

Important nitrogen quality for post-injury states

Builds up the immune system, producing immunoglobulins and antibodies

Metabolizes sugars and organic acids

L-Arginine

Indispensable for optimum growth

Stimulates the release of growth hormone

Important to muscle metabolism; acts as a vehicle for transport, storage and excretion of

nitrogen

Increases muscle mass while decreasing the amount of body fat

Plays an important role in post-injury problems such as weight changes, nitrogen balance and tissue healing

Increases collagen, the main supportive fibrous protein found in bone, cartilage and other connective tissues

Stimulates the Immune system

Combats physical and mental fatigue

Increases spermatogenesis

Used in the treatment of hepatic (liver) disorders

Transforms to L-Ornithine and urea

Promotes the detoxification of ammonia which is poisonous to living cell

L-Aspartic Acid

Increases resistance to fatigue

Involved in the formation of RNA and DNA, the chemical bases of heredity and carriers of genetic information

Salts of aspartic acid increase stamina and endurance

Protects the liver and promotes normal cell function

Builds up the immune system, producing immunoglobulins and antibodies

L-Glutamic Acid

Especially important in brain metabolism

Functions as a brain fuel serving as an excitatory neurotransmitter

Combines to form L-Glutamine and in the process picks up ammonia radicals

This the only method the brain has detoxifying ammonia

Instrumental in the metabolism of amino acids

Metabolizes sugars and fats

Increases the blood sugar level; used in the treatment of hypoglycemia

L-Glycine

Of special value as a source of creatine which is essential for muscle function, breaking down glycogen and freeing energy

Produces glucogen which mobilizes glycogen (a stored energy source of glucose) from the liver

Builds up the immune system, producing immunoglobin and antibodies

Acts as a nitrogen pool for the synthesis of non essential amino acids

Effective for hyperacidity (used in many gastric antacid agents)

L- Histidine

Used in the treatment of allergic diseases

Used in the treatment of rheumatoid arthritis

Effective in the treatment of ulcers of the digestive organs

Important in the production of red and white blood cells; used in the treatment of anemia

L- Isoleucine

Primarily metabolized in muscle tissue

Essential to the formation of hemoglobin

Should always be in well balanced proportion with L-Leucine and L-Valine

Used in combination with L-leucine and L-valine for muscle and liver disorders

L-Leucine

Metabolized in muscle tissue.

Promotes healing of skin and broken bones

Lowers elevated blood sugar levels

Should always be in well balanced proportion with l-Isoleucine and l-Valine

Used in combination with L-isoleucine and L-valine for muscle and liver disorders

L-Lysine

Inhibits the growth of virus’s

Used in the treatment of herpe’s simplex virus

Produces L-carnitine which improves stress tolerance and fat metabolism and has an

Anti-fatigue effect

Promotes bone growth by helping to form collagen, the fibrous protein which makes up

Bone, cartilage and other connective tissues

Aids in the absorption of calcium

L-Methione

Is lipotropic, preventing excessive fat buildup in the liver

Helps prevent premature hair loss

Interacts with other body substances to detoxify harmful compounds

Is included in nutritional supplementation as an anti-fatigue

L-Phenylalanine

Produces and maintains an elevated and positive mood, alertness and ambition

Enhances learning and memory

Produces neurotransmitters which control impulse transmission between nerve cells

Is involved in dopamine transmission

Used in the treatment of certain types of depression

Suppresses appetite

L-Proline

Promotes healing

Glycogenic (energy storage source of glucose by the liver and muscles)

A major constituent of collagen, the main fibrous protein found in bone, cartilage and other connective tissue

L-Serine

Glycogenic (energy storage source of glucose by the liver and muscles)

Builds up the immune system, producing immunoglobulins and antibodies

L-Threonine

Is lipotropic, preventing fatty buildup in the liver

Glycogenic (energy storage source of glucose by the liver and muscles)

Essential to normal growth

Generally low in vegetarian diets

Builds up the immune system, producing immunoglobins and antibodies

Is an important constituent of collagen and elastin proteins

L-Tyrosine

Plays an important role in the function of the adrenal, pituitary and thyroid glands

Generates white and red blood cells

Elevates mood

Is used in the treatment of anxiety, depression and insomnia

Produces Melanin, the skin and hair pigment

Produces norepinephrine, an appetite inhibitory neurotransmitter that suppresses appetite

Stimulates the release of growth hormone which causes muscle growth and reduces body fat

L-Valine

Glycogenic (energy storage source of glucose by the liver and the muscles)

Metabolized in muscle

Should always be in well balanced proportion with L-Leucine and L-Isoleucine

Used in the treatment of severe amino acid deficiencies caused by addictions

Conventional medicine holds the belief that aging is associated with debilitating symptoms and progressive deterioration and decline that cannot be altered.  While the aging process is inevitable, we are entering a new era in mainstream medicine that focuses on prevention of disease and living with energy and vitality.

Our Preventative and Age Management Protocol is based on early detection, prevention, and reversal of the degenerative effects of aging.  The primary goal is living healthier for a longer period of time.  The principles are well documented in medical and scientific journals, and are based on sound and responsible health care.

Research suggests that aging is likely due to a combination of causes that include degeneration of bodily functions due to hormone decline, nutritional deficiencies, free radical damage due to lifestyle factors, chronic inflammation, cardiovascular disease, and insulin resistance.  When these events are controlled or prevented, the likelihood of illness and disability is reduced or prevented, and it becomes possible to maintain good general health, strong muscles and bones, an efficient immune system, sharp memory and peak mental and physical function at any age.

1.  Diet

Some of the leading causes of death in America are heart disease, cancer, stroke, lung disease, injuries, diabetes, flu and pneumonia.  These are all modifiable with dietary lifestyle intervention.  The Mediterranean-style diet is a nutritional program that will effectively reduce the markers of inflammation and promote weight loss.  The diet has 30-35% fat; 20-30% protein; 40-50% carbohydrates.  The basic principles are to cut out sugar and refined carbohydrates, eat more lean protein, replace unhealthy fats with healthful fats and consume the widest variety of fruits and vegetables.

2. Exercise

There are three main exercise categories: resistance/weight training, cardiovascular exercise, and flexibility.  Each offers specific benefits, creating a well-balanced program with dynamic results.

3. Micronutrient Supplementation and the Broad Spectrum Approach

Studies of the American diet reveal sub-optimal intake of micronutrients that lead to degenerative disease, worldwide.  We are inundated with environmental carcinogens, toxins in our food supply, processed fast foods, pesticides and other overwhelming substances.

Micronutrient supplements are not an indulgence.  It is extremely important to supplement when dieting, and even the healthiest diet requires supplementing with amino acids, vitamins, minerals, essential fatty acids and antioxidants.

Commonly commercial formulations vary widely in quality.  Some supplements do not contain the amount of nutrient their label claims; others use inferior ingredients and are less absorbable.

“Food Grade” supplements, like those sold in health food stores often only meet the RDA and lack the organic carriers that ensure optimal absorption.  We carry the most effective and highly researched micronutrient supplements available on the planet.

Total Amino Solution™, made by Genesa Inc. is a free-form, full spectrum amino acid supplement that absorbs within 10 minutes.  Amino Acids are the building blocks of the body and a must for a youthful skin, and a healthy body.  Amino acids are the precursors to all 50 neurotransmitters in the brain.  The only function of our DNA is to string these proteins together. It also strengthens immune function as we age.

Take a highly absorbable full spectrum vitamin and mineral supplement.  Vitamins and minerals play an important role in every level of structure and function of the human body, including the central nervous system, immune system, and the mechanisms that promote longevity.

Omega 3’s play a vital role in protecting cell membranes, decreasing inflammation, balancing blood sugar, and promoting brain derived neurotropic factor, which acts as a fertilizer to enhance dendrite re-growth.

4. Hormone Therapy

The degenerative process known as aging occurs precisely because of our declining hormones.  Hormonal deficiency symptoms include weight gain, loss of muscle mass, degenerative disease ( diabetes mellitus, cancer, heart disease, osteoporosis), a compromised immune system, wrinkling and thinning of the skin, depression and stress, cognitive decline, insulin resistance, loss of sex drive, fatigue and sleep disorders.  Replenishment of these hormones to optimal, youthful levels through bio-identical hormone replacement therapy (BHRT) can delay, prevent or even reverse the effects of aging.

Bio-identical hormones are by definition identical to those already found in the human body.  They mimic the shape and function of our own endogenous hormones.  The body treats and processes them in the same way it has processed its natural hormones for years.  Unfortunately, many of the hormones regularly prescribed are not identical to those found in the human body.  As the body works to metabolize – these foreign substances, it may produce toxic by-products, which can cause many side effects such as bloating, mood swings, water retention and serious problems such as heart disease and cancer.

We are all concerned about the seemingly inevitable increases in heart disease, adult onset diabetes, sarcopenia (muscle wasting associated with aging), age related depression, and loss of memory. Research over the past few years has shown daily supplementation of essential amino acids improves muscle mass with or without exercise [3,29,58], as well as improving insulin resistance, [2,60,61,72-74] a common complication of aging and precursor to the development of type II adult onset diabetes.

Amino acid supplements protect the brain and heart and increase muscle mitochondria while reducing muscle fibrosis (inactive fibrous tissue replacing healthy muscle).[10,28,55] Mitochondria are the powerhouses of all of our cells and aging is associated with decreased mitochondria in muscle and brain. Restoring essential mitochondria is an important part of any anti-aging program.

Amino acid supplements increase the production of essential enzymes which enhance and protect muscle (including the heart) and brain. We often think of enzymes in terms of digestion, and amino acids do support healthy digestion, but every metabolic change throughout the body and brain is controlled and modified by enzymes. [5,61,65,70,78]

Exercise is important for both body and brain. Significant daily exercise reduces blood pressure, heart disease, insulin resistance, obesity, osteoporosis and even depression. [4,22,23,26,45,46,49,50,53,54,58,67,80] When exercising is difficult, because of fatigue, weakness, or muscle insufficiency, amino acid supplements have been shown to improve exercise capacity. [1,6,21,23,69-71]

Inactivity, often accompanying aging and illness, alters the body’s ability to utilize protein. Amino acid supplements, which require no digestion, show potential to reverse this condition, as well as the muscle wasting caused by corticosteroid medications. [25,56] This in turn may allow one to begin a regular program of physical activity further increasing longevity.

Total Amino Solution is a complete amino acid supplement which addresses issues of aging by providing not just a complement of essential amino acids but further increases its effectiveness by providing several conditionally essential amino acids. These include l-carnitine to improve fat burning, cognitive function, and heart function [35,38,39,44,48,51], and taurine, a membrane stabilizer, anti-oxidant, and calcium stabilizer, as well as a key component of the functioning muscle, heart, brain and eye.[11,14,20,33,36,41,47,52,62,64,79] In addition taurine, along with other aminos, has shown benefit to learning and memory retention and is necessary for a functioning immune system. [19,65]

Total Amino Solution has been further enhanced by the addition of a complement of the B vitamins niacinamide, riboflavin, pyridoxal-5-phospate, folic acid, and B-12  which provide the essential elements for production of critical enzymes through out the body and brain. These B vitamins have been clinically shown to decrease homocysteine, a problematic by product of metabolism that when elevated is associated with dementias, heart disease, osteoporosis, depression, and even mobility. [7-9,15-17,24,31,34,37,42]

B vitamin status is often overlooked in the diet of seniors. Hyperhomocysteinemia (elevated homocysteine) is a common finding in this group and both additional B vitamins, especially B-6, folic acid and B-12, and protein, which might include a complete amino acid such as Total Amino Solution, lower homocysteine. [7,13,32,76]

Further B-12, folic acid, and elevated homocysteine have been shown to be related to thyroid insufficiency in aging.[75] These two important B vitamins have also been associated with hearing loss in older adults. [18,59] Thyroid problems increase incidence of immobility and depression and dramatically decrease quality of life, as does loss of hearing.

The amino acids found in Total Amino Solution combined with the complex of B vitamins synergistically support healthy aging. As we age understanding our decreased need for calories combined with an increased need for essential nutrition, including amino acids and B vitamins, gives us the knowledge we need to support our bodies so that we may enjoy a long and healthy life.

Dr. Daniel S. Smith, DC

Genesa, Inc

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By Marcia Angell

1.

Every day Americans are subjected to a barrage of advertising by the pharmaceutical industry. Mixed in with the pitches for a particular drug—usually featuring beautiful people enjoying themselves in the great outdoors—is a more general message. Boiled down to its essentials, it is this: “Yes, prescription drugs are expensive, but that shows how valuable they are. Besides, our research and development costs are enormous, and we need to cover them somehow. As ‘research-based’ companies, we turn out a steady stream of innovative medicines that lengthen life, enhance its quality, and avert more expensive medical care. You are the beneficiaries of this ongoing achievement of the American free enterprise system, so be grateful, quit whining, and pay up.” More prosaically, what the industry is saying is that you get what you pay for.

Is any of this true? Well, the first part certainly is. Prescription drug costs are indeed high—and rising fast. Americans now spend a staggering $200 billion a year on prescription drugs, and that figure is growing at a rate of about 12 percent a year (down from a high of 18 percent in 1999).^[1] Drugs are the fastest-growing part of the health care bill—which itself is rising at an alarming rate. The increase in drug spending reflects, in almost equal parts, the facts that people are taking a lot more drugs than they used to, that those drugs are more likely to be expensive new ones instead of older, cheaper ones, and that the prices of the most heavily prescribed drugs are routinely jacked up, sometimes several times a year.

Many of them simply can’t do it. They trade off drugs against home heating or food. Some people try to string out their drugs by taking them less often than prescribed, or sharing them with a spouse. Others, too embarrassed to admit that they can’t afford to pay for drugs, leave their doctors’ offices with prescriptions in hand but don’t have them filled. Not only do these patients go without needed treatment but their doctors sometimes wrongly conclude that the drugs they prescribed haven’t worked and prescribe yet others—thus compounding the problem.

The people hurting most are the elderly. When Medicare was enacted in 1965, people took far fewer prescription drugs and they were cheap. For that reason, no one thought it necessary to include an outpatient prescription drug benefit in the program. In those days, senior citizens could generally afford to buy whatever drugs they needed out of pocket. Approximately half to two thirds of the elderly have supplementary insurance that partly covers prescription drugs, but that percentage is dropping as employers and insurers decide it is a losing proposition for them. At the end of 2003, Congress passed a Medicare reform bill that included a prescription drug benefit scheduled to begin in 2006, but as we shall see later, its benefits are inadequate to begin with and will quickly be overtaken by rising prices and administrative costs.

For obvious reasons, the elderly tend to need more prescription drugs than younger people—mainly for chronic conditions like arthritis, diabetes, high blood pressure, and elevated cholesterol. In 2001, nearly one in four seniors reported that they skipped doses or did not fill prescriptions because of the cost. (That fraction is almost certainly higher now.) Sadly, the frailest are the least likely to have supplementary insurance. At an average cost of $1,500 a year for each drug, someone without supplementary insurance who takes six different prescription drugs—and this is not rare—would have to spend $9,000 out of pocket. Not many among the old and frail have such deep pockets.

Furthermore, in one of the more perverse of the pharmaceutical industry’s practices, prices are much higher for precisely the people who most need the drugs and can least afford them. The industry charges Medicare recipients without supplementary insurance much more than it does favored customers, such as large HMOs or the Veterans Affairs (VA) system. Because the latter buy in bulk, they can bargain for steep discounts or rebates. People without insurance have no bargaining power; and so they pay the highest prices.

But while the rhetoric is stirring, it has very little to do with reality. First, research and development (R&D) is a relatively small part of the budgets of the big drug companies—dwarfed by their vast expenditures on marketing and administration, and smaller even than profits. In fact, year after year, for over two decades, this industry has been far and away the most profitable in the United States. (In 2003, for the first time, the industry lost its first-place position, coming in third, behind “mining, crude oil production,” and “commercial banks.”) The prices drug companies charge have little relationship to the costs of making the drugs and could be cut dramatically without coming anywhere close to threatening R&D.

Second, the pharmaceutical industry is not especially innovative. As hard as it is to believe, only a handful of truly important drugs have been brought to market in recent years, and they were mostly based on taxpayer-funded research at academic institutions, small biotechnology companies, or the National Institutes of Health (NIH). The great majority of “new” drugs are not new at all but merely variations of older drugs already on the market. These are called “me-too” drugs. The idea is to grab a share of an established, lucrative market by producing something very similar to a top-selling drug. For instance, we now have six statins (Mevacor, Lipitor, Zocor, Pravachol, Lescol, and the newest, Crestor) on the market to lower cholesterol, all variants of the first. As Dr. Sharon Levine, associate executive director of the Kaiser Permanente Medical Group, put it,

If I’m a manufacturer and I can change one molecule and get another twenty years of patent rights, and convince physicians to prescribe and consumers to demand the next form of Prilosec, or weekly Prozac instead of daily Prozac, just as my patent expires, then why would I be spending money on a lot less certain endeavor, which is looking for brand-new drugs?^[4]

Third, the industry is hardly a model of American free enterprise. To be sure, it is free to decide which drugs to develop (me-too drugs instead of innovative ones, for instance), and it is free to price them as high as the traffic will bear, but it is utterly dependent on government-granted monopolies—in the form of patents and Food and Drug Administration (FDA)–approved exclusive marketing rights. If it is not particularly innovative in discovering new drugs, it is highly innovative—and aggressive—in dreaming up ways to extend its monopoly rights.

And there is nothing peculiarly American about this industry. It is the very essence of a global enterprise. Roughly half of the largest drug companies are based in Europe. (The exact count shifts because of mergers.) In 2002, the top ten were the American companies Pfizer, Merck, Johnson & Johnson, Bristol-Myers Squibb, and Wyeth (formerly American Home Products); the British companies GlaxoSmithKline and AstraZeneca; the Swiss companies Novartis and Roche; and the French company Aventis (which in 2004 merged with another French company, Sanafi Synthelabo, putting it in third place).^[5] All are much alike in their operations. All price their drugs much higher here than in other markets.

Since the United States is the major profit center, it is simply good public relations for drug companies to pass themselves off as American, whether they are or not. It is true, however, that some of the European companies are now locating their R&D operations in the United States. They claim the reason for this is that we don’t regulate prices, as does much of the rest of the world. But more likely it is that they want to feed on the unparalleled research output of American universities and the NIH. In other words, it’s not private enterprise that draws them here but the very opposite—our publicly sponsored research enterprise.

If prescription drugs were like ordinary consumer goods, all this might not matter very much. But drugs are different. People depend on them for their health and even their lives. In the words of Senator Debbie Stabenow (D-Mich.), “It’s not like buying a car or tennis shoes or peanut butter.” People need to know that there are some checks and balances on this industry, so that its quest for profits doesn’t push every other consideration aside. But there aren’t such checks and balances.

2.

What does the eight-hundred-pound gorilla do? Anything it wants to.

What’s true of the eight-hundred-pound gorilla is true of the colossus that is the pharmaceutical industry. It is used to doing pretty much what it wants to do. The watershed year was 1980. Before then, it was a good business, but afterward, it was a stupendous one. From 1960 to 1980, prescription drug sales were fairly static as a percent of US gross domestic product, but from 1980 to 2000, they tripled. They now stand at more than $200 billion a year.^[6] Of the many events that contributed to the industry’s great and good fortune, none had to do with the quality of the drugs the companies were selling.

The claim that drugs are a $200 billion industry is an understatement. According to government sources, that is roughly how much Americans spent on prescription drugs in 2002. That figure refers to direct consumer purchases at drugstores and mail-order pharmacies (whether paid for out of pocket or not), and it includes the nearly 25 percent markup for wholesalers, pharmacists, and other middlemen and retailers. But it does not include the large amounts spent for drugs administered in hospitals, nursing homes, or doctors’ offices (as is the case for many cancer drugs). In most analyses, they are allocated to costs for those facilities.

Drug company revenues (or sales) are a little different, at least as they are reported in summaries of corporate annual reports. They usually refer to a company’s worldwide sales, including those to health facilities. But they do not include the revenues of middlemen and retailers.

Perhaps the most quoted source of statistics on the pharmaceutical industry, IMS Health, estimated total worldwide sales for prescription drugs to be about $400 billion in 2002. About half were in the United States. So the $200 billion colossus is really a $400 billion megacolossus.

The pharmaceutical industry and its CEOs quickly joined the ranks of the winners as a result of a number of business-friendly government actions. I won’t enumerate all of them, but two are especially important. Beginning in 1980, Congress enacted a series of laws designed to speed the translation of tax-supported basic research into useful new products—a process sometimes referred to as “technology transfer.” The goal was also to improve the position of American-owned high-tech businesses in world markets.

The most important of these laws is known as the Bayh-Dole Act, after its chief sponsors, Senator Birch Bayh (D-Ind.) and Senator Robert Dole (R-Kans.). Bayh-Dole enabled universities and small businesses to patent discoveries emanating from research sponsored by the National Institutes of Health, the major distributor of tax dollars for medical research, and then to grant exclusive licenses to drug companies. Until then, taxpayer-financed discoveries were in the public domain, available to any company that wanted to use them. But now universities, where most NIH-sponsored work is carried out, can patent and license their discoveries, and charge royalties. Similar legislation permitted the NIH itself to enter into deals with drug companies that would directly transfer NIH discoveries to industry.

Bayh-Dole gave a tremendous boost to the nascent biotechnology industry, as well as to big pharma. Small biotech companies, many of them founded by university researchers to exploit their discoveries, proliferated rapidly. They now ring the major academic research institutions and often carry out the initial phases of drug development, hoping for lucrative deals with big drug companies that can market the new drugs. Usually both academic researchers and their institutions own equity in the biotechnology companies they are involved with. Thus, when a patent held by a university or a small biotech company is eventually licensed to a big drug company, all parties cash in on the public investment in research.

The Reagan years and Bayh-Dole also transformed the ethos of medical schools and teaching hospitals. These nonprofit institutions started to see themselves as “partners” of industry, and they became just as enthusiastic as any entrepreneur about the oppor-tunities to parlay their discoveries in-to financial gain. Faculty researchers were encouraged to obtain patents on their work (which were assigned to their universities), and they shared in the royalties. Many medical schools and teaching hospitals set up “technology transfer” offices to help in this activity and capitalize on faculty discoveries. As the entrepreneurial spirit grew during the 1990s, medical school faculty entered into other lucrative financial arrangements with drug companies, as did their parent institutions.

One of the results has been a growing pro-industry bias in medical research—exactly where such bias doesn’t belong. Faculty members who had earlier contented themselves with what was once referred to as a “threadbare but genteel” lifestyle began to ask themselves, in the words of my grandmother, “If you’re so smart, why aren’t you rich?” Medical schools and teaching hospitals, for their part, put more resources into searching for commercial opportunities.

Starting in 1984, with legislation known as the Hatch-Waxman Act, Congress passed another series of laws that were just as big a bonanza for the pharmaceutical industry. These laws extended monopoly rights for brand-name drugs. Exclusivity is the lifeblood of the industry because it means that no other company may sell the same drug for a set period. After exclusive marketing rights expire, copies (called generic drugs) enter the market, and the price usually falls to as little as 20 percent of what it was.^[9] There are two forms of monopoly rights—patents granted by the US Patent and Trade Office (USPTO) and exclusivity granted by the FDA. While related, they operate somewhat independently, almost as backups for each other. Hatch-Waxman, named for Senator Orrin Hatch (R-Utah) and Representative Henry Waxman (D-Calif.), was meant mainly to stimulate the foundering generic industry by short-circuiting some of the FDA requirements for bringing generic drugs to market. While successful in doing that, Hatch-Waxman also lengthened the patent life for brand-name drugs. Since then, industry lawyers have manipulated some of its provisions to extend patents far longer than the lawmakers intended.

In the 1990s, Congress enacted other laws that further increased the patent life of brand-name drugs. Drug companies now employ small armies of lawyers to milk these laws for all they’re worth—and they’re worth a lot. The result is that the effective patent life of brand-name drugs increased from about eight years in 1980 to about fourteen years in 2000.^[10] For a blockbuster—usually defined as a drug with sales of over a billion dollars a year (like Lipitor or Celebrex or Zoloft)—those six years of additional exclusivity are golden. They can add billions of dollars to sales—enough to buy a lot of lawyers and have plenty of change left over. No wonder big pharma will do almost anything to protect exclusive marketing rights, despite the fact that doing so flies in the face of all its rhetoric about the free market.

In 2002, as the economic downturn continued, big pharma showed only a slight drop in profits—from 18.5 to 17.0 percent of sales. The most startling fact about 2002 is that the combined profits for the ten drug companies in the Fortune 500 ($35.9 billion) were more than the profits for all the other 490 businesses put together ($33.7 billion).^[12] In 2003 profits of the Fortune 500 drug companies dropped to 14.3 percent of sales, still well above the median for all industries of 4.6 percent for that year. When I say this is a profitable industry, I mean really profitable. It is difficult to conceive of how awash in money big pharma is.

Drug industry expenditures for research and development, while large, were consistently far less than profits. For the top ten companies, they amounted to only 11 percent of sales in 1990, rising slightly to 14 percent in 2000. The biggest single item in the budget is neither R&D nor even profits but something usually called “marketing and administration”—a name that varies slightly from company to company. In 1990, a staggering 36 percent of sales revenues went into this category, and that proportion remained about the same for over a decade.^[13] Note that this is two and a half times the expenditures for R&D.

These figures are drawn from the industry’s own annual reports to the Securities and Exchange Commission (SEC) and to stockholders, but what actually goes into these categories is not at all clear, because drug companies hold that information very close to their chests. It is likely, for instance, that R&D includes many activities most people would consider marketing, but no one can know for sure. For its part, “marketing and administration” is a gigantic black box that probably includes what the industry calls “education,” as well as advertising and promotion, legal costs, and executive salaries—which are whopping. According to a report by the non-profit group Families USA, the for-mer chairman and CEO of Bristol-Myers Squibb, Charles A. Heimbold Jr., made $74,890,918 in 2001, not counting his $76,095,611 worth of unexercised stock options. The chairman of Wyeth made $40,521,011, exclusive of his $40,629,459 in stock options. And so on.^[14]

3.

If 1980 was a watershed year for the pharmaceutical industry, 2000 may very well turn out to have been another one—the year things began to go wrong. As the booming economy of the late 1990s turned sour, many successful businesses found themselves in trouble. And as tax revenues dropped, state governments also found themselves in trouble. In one respect, the pharmaceutical industry is well protected against the downturn, since it has so much wealth and power. But in another respect, it is peculiarly vulnerable, since it depends on employer-sponsored insurance and state-run Medicaid programs for much of its revenues. When employers and states are in trouble, so is big pharma.

And sure enough, in just the past couple of years, employers and the private health insurers with whom they contract have started to push back against drug costs. Most big managed care plans now bargain for steep price discounts. Most have also instituted three-tiered coverage for prescription drugs—full coverage for generic drugs, partial coverage for useful brand-name drugs, and no coverage for expensive drugs that offer no added benefit over cheaper ones. These lists of preferred drugs are called formularies, and they are an increasingly important method for containing drug costs. Big pharma is feeling the effects of these measures, although not surprisingly, it has become adept at manipulating the system—mainly by inducing doctors or health plans to put expensive, brand-name drugs on formularies.

State governments, too, are looking for ways to cut their drug costs. Some state legislatures are drafting measures that would permit them to regulate prescription drug prices for state employees, Medicaid recipients, and the uninsured. Like managed care plans, they are creating formularies of preferred drugs. The industry is fighting these efforts—mainly with its legions of lobbyists and lawyers. It fought the state of Maine all the way to the US Supreme Court, which in 2003 upheld Maine’s right to bargain with drug companies for lower prices, while leaving open the details. But that war has just begun, and it promises to go on for years and get very ugly.

Recently the public has shown signs of being fed up. The fact that Americans pay much more for prescription drugs than Europeans and Canadians is now widely known. An estimated one to two million Americans buy their medicines from Canadian drugstores over the Internet, despite the fact that in 1987, in response to heavy industry lobbying, a compliant Congress had made it illegal for anyone other than manufacturers to import prescription drugs from other countries.^[15] In addition, there is a brisk traffic in bus trips for people in border states, particularly the elderly, to travel to Canada or Mexico to buy prescription drugs. Their resentment is palpable, and they constitute a powerful voter block—a fact not lost on Congress or state legislatures.

The industry faces other, less familiar problems. It happens that, by chance, some of the top-selling drugs—with combined sales of around $35 billion a year—are scheduled to go off patent within a few years of one another.^[16] This drop over the cliff began in 2001, with the expiration of Eli Lilly’s patent on its blockbuster antidepressant Prozac. In the same year, AstraZeneca lost its patent on Prilosec, the original “purple pill” for heartburn, which at its peak brought in a stunning $6 billion a year. Bristol-Myers Squibb lost its best-selling diabetes drug, Glucophage. The unusual cluster of expirations will continue for another couple of years. While it represents a huge loss to the industry as a whole, for some companies it’s a disaster. Schering-Plough’s blockbuster allergy drug, Claritin, brought in fully a third of that company’s revenues before its patent expired in 2002.^[17] Claritin is now sold over the counter for much less than its prescription price. So far, the company has been unable to make up for the loss by trying to switch Claritin users to Clarinex—a drug that is virtually identical but has the advantage of still being on patent.

Even worse is the fact that there are very few drugs in the pipeline ready to take the place of blockbusters going off patent. In fact, that is the biggest problem facing the industry today, and its darkest secret. All the public relations about innovation is meant to obscure precisely this fact. The stream of new drugs has slowed to a trickle, and few of them are innovative in any sense of that word. Instead, the great majority are variations of oldies but goodies—”me-too” drugs.

Of the seventy-eight drugs approved by the FDA in 2002, only seventeen contained new active ingredients, and only seven of these were classified by the FDA as improvements over older drugs. The other seventy-one drugs approved that year were variations of old drugs or deemed no better than drugs already on the market. In other words, they were me-too drugs. Seven of seventy-eight is not much of a yield. Furthermore, of those seven, not one came from a major US drug company.^[18]

The hints of trouble and the public’s growing resentment over high prices are producing the first cracks in the industry’s formerly firm support in Washington. In 2000, Congress passed legislation that would have closed some of the loopholes in Hatch-Waxman and also permitted American pharmacies, as well as individuals, to import drugs from certain countries where prices are lower. In particular, they could buy back FDA-approved drugs from Canada that had been exported there. It sounds silly to “reimport” drugs that are marketed in the United States, but even with the added transaction costs, doing so is cheaper than buying them here. But the bill required the secretary of health and human services to certify that the practice would not pose any “added risk” to the public, and secretaries in both the Clinton and Bush administrations, under pressure from the industry, refused to do that.

The industry is also being hit with a tidal wave of government investigations and civil and criminal lawsuits. The litany of charges includes illegally overcharging Medicaid and Medicare, paying kickbacks to doctors, engaging in anticompetitive practices, colluding with generic companies to keep generic drugs off the market, illegally promoting drugs for unapproved uses, engaging in misleading direct-to-consumer advertising, and, of course, covering up evidence. Some of the settlements have been huge. TAP Phar- maceuticals, for instance, paid $875 million to settle civil and criminal charges of Medicaid and Medicare fraud in the marketing of its prostate cancer drug, Lupron.^[19] All of these efforts could be summed up as increasingly desperate marketing and patent games, activities that always skirted the edge of legality but now are sometimes well on the other side.

How is the pharmaceutical industry responding to its difficulties? One could hope drug companies would decide to make some changes—trim their prices, or at least make them more equitable, and put more of their money into trying to discover genuinely innovative drugs, instead of just talking about it. But that is not what is happening. Instead, drug companies are doing more of what got them into this situation. They are marketing their me-too drugs even more relentlessly. They are pushing even harder to extend their monopolies on top-selling drugs. And they are pouring more money into lobbying and political campaigns. As for innovation, they are still waiting for Godot.

The news is not all bad for the industry. The Medicare prescription drug benefit enacted in 2003, and scheduled to go into effect in 2006, promises a windfall for big pharma since it for-bids the government from negotiating prices. The immediate jump in pharmaceutical stock prices after the bill passed indicated that the industry and investors were well aware of the windfall. But at best, this legislation will be only a temporary boost for the industry. As costs rise, Congress will have to reconsider its industry-friendly decision to allow drug companies to set their own prices, no questions asked.

Clearly, the pharmaceutical industry is due for fundamental reform. Reform will have to extend beyond the industry to the agencies and institutions it has co-opted, including the FDA and the medical profession and its teaching centers. In my forthcoming book, The Truth About the Drug Companies, I discuss the major reforms that will be necessary.

For example, we need to get the industry to focus on discovering truly innovative drugs instead of turning out me-too drugs (and spending billions of dollars to promote them as though they were miracles). The me-too business is made possible by the fact that the FDA usually approves a drug only if it is better than a placebo. It needn’t be better than an older drug already on the market to treat the same condition; in fact, it may be worse. There is no way of knowing, since companies generally do not test their new drugs against older ones for the same conditions at equivalent doses. (For obvious reasons, they would rather not find the answer.) They should be required to do so.

The me-too market would collapse virtually overnight if the FDA made approval of new drugs contingent on their being better in some important way than older drugs already on the market. Probably very few new drugs could meet that test. By default, then, drug companies would have to concentrate on finding truly innovative drugs, and we would finally find out whether this much-vaunted industry is turning out better drugs. A welcome by-product of this reform is that it would also reduce the incessant and enormously expensive marketing necessary to jockey for position in the me-too market. Genuinely important new drugs do not need much promotion (imagine having to advertise a cure for cancer).

A second important reform would be to require drug companies to open their books. Drug companies reveal very little about the most crucial aspects of their business. We know next to nothing about how much they spend to bring each drug to market or what they spend it on. (We know that it is not $802 million, as some industry apologists have recently claimed.) Nor do we know what their gigantic “marketing and administration” budgets cover. We don’t even know the prices they charge their various customers. Perhaps most important, we do not know the results of the clinical trials they sponsor—only those they choose to make public, which tend to be the most favorable findings. (The FDA is not allowed to reveal the results it has.) The industry claims all of this is “proprietary” information. Yet, unlike other businesses, drug companies are dependent on the public for a host of special favors—including the rights to NIH-funded research, long periods of market monopoly, and multiple tax breaks that almost guarantee a profit. Because of these special favors and the importance of its products to public health, as well as the fact that the government is a major purchaser of its products, the pharmaceutical industry should be regarded much as a public utility.

These are just two of many reforms I advocate in my book. Some of the others have to do with breaking the dependence of the medical profession on the industry and with the inappropriate control drug companies have over the evaluation of their own products. The sort of thoroughgoing changes required will take government action, which in turn will require strong public pressure. It will be tough. Drug companies have the largest lobby in Washington, and they give copiously to political campaigns. Legislators are now so beholden to the pharmaceutical industry that it will be exceedingly difficult to break its lock on them.

But the one thing legislators need more than campaign contributions is votes. That is why citizens should know what is really going on. Contrary to the industry’s public relations, they don’t get what they pay for. The fact is that this industry is taking us for a ride, and there will be no real reform without an aroused and determined public to make it happen.

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Notes

^[1] There are several sources of statistics on the size and growth of the industry. One is IMS Health (www.imshealth .com), a private company that collects and sells information on the global pharmaceutical industry. See www .imshealth.com/ims/portal/front/articleC/0,2777,6599_3665_41336931,00. html for the $200 billion figure. For further sources on this and other matters, see my book The Truth About the Drug Companies: How They Deceive Us and What to Do About It (to be published in August by Random House), from which this article is drawn.

^[2] For a full picture of the special burden of rising drug prices on senior citizens, see Families USA, “Out-of-Bounds: Rising Prescription Drug Prices for Seniors” (www.familiesusa .org/site/PageServer?pagename=Publications_Reports).

^[3] Sarah Lueck, “Drug Prices Far Outpace Inflation,” The Wall Street Journal, July 10, 2003, p. D2.

^[4] On ABC Special with Peter Jennings, “Bitter Medicine: Pills, Profit, and the Public Health,” May 29, 2002.

^[5] For the top ten companies and their recent mergers as of 2003, see www .oligopolywatch.com/2003/05/25.html.

^[6] These figures come from the US Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group, Baltimore, Maryland. They were summarized in Cynthia Smith, “Retail Prescription Drug Spending in the National Health Accounts,” Health Affairs, January– February 2004, p. 160.

^[7] For excellent summaries of public contributions to drug company research, see Public Citizen Congress Watch, “Rx R&D Myths: The Case Against the Drug Industry’s R&D ‘Scare Card,’” July 2001 (www.citizen.org); and NIHCM, “Changing Patterns of Pharmaceutical Innovation,” May 2002 (www.nihcm.org).

^[8] This is probably an underestimate. One source that indicates it is at least this is CenterWatch, www.centerwatch .com, a private company owned by Thomson Medical Economics, which provides information to the clinical trial industry. See An Industry in Evolution, third edition, edited by Mary Jo Lamberti (CenterWatch, 2001), p. 22.

^[9] Families USA, “Out-of-Bounds: Rising Prescription Drug Prices for Seniors.”

^[10] Public Citizen Congress Watch, “Rx R&D Myths.”

^[11] “The Fortune 500,” Fortune, April 15, 2002, p. F26.

^[12] Public Citizen Congress Watch, “Drug Industry Profits: Hefty Pharmaceutical Company Margins Dwarf Other Industries,” June 2003 (www.citizen .org/documents/Pharma_Report.pdf). The data are drawn mainly from the Fortune 500 list in Fortune, April 7, 2003, and drug company annual reports.

^[13] Henry J. Kaiser Family Foundation, “Prescription Drug Trends,” November 2001 (www.kff.org).

^[14] FamiliesUSA, “Profiting from Pain: Where Prescription Drug Dollars Go,” July 2002 (www.familiesusa. org /site/DocServer/PReport.pdf?docID= 249).

^[15] Patricia Barry, “More Americans Go North for Drugs,” AARP Bulletin, April 2003, p. 3.

^[16] Chandrani Ghosh and Andrew Tanzer, “Patent Play,” Forbes, September 17, 2001, p. 141.

^[17] Gardiner Harris, “Schering-Plough Is Hurt by Plummeting Pill Costs,” The New York Times, July 8, 2003, p. C1.

^[18] For key information about the numbers and kinds of drugs approved each year, see the Web site of the US Food and Drug Administration (FDA), www .fda.gov/cder/rdmt/pstable.htm.

^[19] Alice Dembner, “Drug Firm to Pay $875M Fine for Fraud,” The Boston Globe, October 4, 2001, p. A13.

Letters

December 16, 2004: Lawrence Sincich, The Drug Companies and the Universities

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