| Food_Find Nutritional values for common foods. |
| Food_Supplements Information about effects of vitamins and minerals in the body with reference listings for individual nutrients. |
| FoodGenius_com Discover nutrient contents and see if you're getting the RDA. |
| Glyconutrients_Reference Provides research findings, mechanism of action, and details of suppliers. |
| Hydrogenated_Oils__The_Silent_Killers Discusses the effects of hydrogenated oils in the human diet, with numerous references to scientific studies. |
| Lansbergen,_Gabrie Help to define the best fat for your own food application. |
| Life_Research_Universal-_Health_Department Has listing of foods with saturated fat, cholesterol, and calories. Provides menus with fat and caloric content and nutritional values. |
| Lutein_-_The_Vision_Carotenoid Simple and clear information on role of lutein, a plant carotenoid deficient in most western diets, in vision, especially the prevention of 'age-related macular degeneration', as well as overall healt |
| Lycopene A resource on lycopene and its health benefits including current research, media releases, and recipes. |
| Medspice_com Shows how antioxidants and other compounds in spices help to prevent and treat many illnesses including Alzheimer's disease, diabetes, cancer and heart disease. |
| Mike\'s_Calorie_and_Fat_Gram_Chart Has calorie and fat gram chart for 1000 foods sorted by carbohydrates, cholesterol, protein, and fat listed alphabetically. Provides health and fitness links. |
| Natural_Food__Fruit Discusses how we came to be eating the small range of fruits we now eat, and the relative nutritional and protective strengths of commercially available fruit. |
| Natural_Food__Grains_Beans_and_Seeds Covers legumes and seeds and their role in the human diet through human evolution. Focuses on the legume, grain, and seed species worldwide, and is particularly relevant to the legume/grain debate in |
| Natural_Food__Vegetables A discussion of the nutritional values of vegetables during human evolution and today; including the importance of tubers, roots, corms, rhizomes and bulbs during evolution. Includes notes on wild Afr |
| NUT_Nutrition_Software Free nutrition software for Linux and DOS, which records and analyzes meals with the USDA nutrient database. |
| NutraSanus Directory of information on nutritional supplements, herbal supplements and health concerns. |
| Nutrient_Data_Laboratory_Food_Composition_Data Downloadable data sets prepared by the USDA Nutrient Data Laboratory with nutrient values of foods. |
| NutrientFacts_com Offers online nutrition tools that generate nutrition facts labels for any food or recipe. Provides a nutrient almanac designed to aid in planning a healthy, balanced diet. |
| NutrientFinder_com Online nutrient database of over 66,000 raw, cooked and packaged foods. |
| NutriSolutions Information about antioxidants as an alternative treatment for various types of cancer. |
| Nutrition_Facts Information about carbohydrates, fats, trans-fats, sugars, proteins, and other nutritional information about thousands of foods. |
| The_Nutrition_Guide A breakdown of all the nutritional elements of more than 6000 foods. |
| Nutrition__What_should_we_eat? Describes food nutrients with dietary tips, discusses dietary risks, and gives links to additional information including nutrition books. |
| Nutry__Free_Nutrition_Software Offers free nutrition software based on USDA nutrient database. |
| Pecans,_Nutritional_Content_ Fat profile, studies on the effect of pecans and other nuts on blood profiles. From the National Pecan Shellers Association, USA |
| Phytochemicals__Vitamins_of_the_Future? Describes phytochemicals, identifies the foods in which they are found, and suggest ways to obtain them from a diet. |
| Rushing,_Mary For health-care professionals and consumers, glyco- and other concentrated nutrients help the body reclaim its own healing abilities. "Informative Calls" and short history on finding Stem Cells genera |
| Soy_Info_Online Information on soy, soy products, and legumes. Nutrient charts for common legumes, discussion of allergies, phytochemicals, and protective effects. |
| Whey_Protein_Institute Advocates the use of whey proteins in nutrition. Describes nutrition facts and functions complete proteins have in diet. |
| Hodges\'_Health_Career__Model Provides a framework for the assessment and evaluation of health care delivery, associated with models of health and visualization in health care. Includes history, objectives, and frequently asked qu |
| NurseLinx Index to current journal abstracts for general nursing and specialties. |
| Nurse\'s_PDR_Resource_Center Includes monthly alerts, changes and new drug releases. Features the monthly drug column from RN Magazine as well as daily drug news headlines from Individual, Inc. |
| NurseScribe Provides articles on clinical topics, writing, and professional development, and annotated links to writing tools, nursing theory, organizations, and specialties. |
| Nursing_Dosage_Calculators Offers drug calculators including mcg/kg/min, drip rates, body surface area, and metric conversions, and tutorials. |
| Nursing_Ethics Index of Canadian and international resources, including organizations, codes of ethics, selected articles, and forum. |
| Nursing_Journals_on_the_WWW Internet directory of links to nursing journals. |
| Nursing_Online Nursing resources page is a portal for nursing profession containing the links to practice, research, education, and professional organizations. Regional nursing around the world is also provided. |
| Nursing_Resources From the Indiana University School of Nursing, links to recommended references, online journals, professional organizations, and other internet resources. |
| Nursing_Theory_Page Offers literature search tips, and links to sites, conferences and discussion boards. |
| The_Nursing_Workforce_Digest A searchable database of citations and annotations of information about the nursing shortage. |
The number-needed-to-treat to prevent one fracture at 18 months and at 36 months is
given in the table on page 6 with 95% confidence intervals. For hip fractures, the
NNT of 20 means that 20 women have to be treated with calcium and vitamin D for 3
years to prevent a hip fracture in one who would have had a fractured hip had they
all not been treated. The NNT to prevent fractures at any non-vertebral site was 14.
NNT values at 36 months were about twice as good as those at 18 months, indicating
that continued treatment increases the benefit. Over longer periods, it is likely
that the NNT would continue to fall (see [3]).
The data on fractures is buttressed by information from bone density measurements -
an average 3% increase in the treated group compared with a 5% decrease in the
untreated group. Biochemical measures (reduced PTH and increased vitamin D) also
supported improved bone metabolism.
What are the holes in these studies? Few, actually. The data are there for the most
conservative of determinants of efficacy. It might be possible to quibble about the
inclusion criteria, because a small minority of elderly women will be treated with
corticosteroids, thyroxine or anticonvulsants, but not many. No men were studied,
probably because their lifetime risk (5%) is about half that of women (12%).
Controversy
A systematic review of vitamin D supplementation in the Cochrane Library [3] comes to
a different conclusion. It calculates the NNT at 36 months as 40 (95% CI 22 - 210).
The reason for the difference seems to be that these reviewers have taken an "all
patients randomised" view of the denominator for the intention to treat analysis,
whereas the in original paper information from women who died from causes other than
fracture were censored. Increasing the denominator without increasing the numerator
will give larger NNTs and less good effects.
This is an interesting issue. There is a purist line which would support not
censoring, but in a population where all cause death rates are high, reducing hip
fractures in those still living is clearly the clinical outcome desired. Perhaps the
key lesson is that if
different
interventions were to be compared to prevent hip fracture, then they should be
compared on the same basis, whether that was censored or not censored data. This may
be particularly important when it comes to cost-effectiveness analysis.
Cost effective?
Depends, especially with the NNT consideration above.
The cost of a broken hip has been estimated at [sterling]5,000 (strictly hospital
medical costs [4]), but others have suggested much higher figures. At the Bandolier
conference, figures as high as [sterling]17,500 were suggested. Prophylactic
treatment of high-risk patients would be worthwhile if the cost of prophylaxis was
about the same or less than the cost of treating a fractured hip. The combination
used in the Chapuy study was Ostram, costing about 20p a day or [sterling]73 per
person for a year.
With a NNT of 20, twenty patients would have to be treated for three years to prevent
a hip fracture in one of them, so the cost of prevention would be [sterling]4,400.
With a NNT of 40, but accepting that some people would not use three year's worth of
supplement, the cost would be likely to be less than [sterling]8,800 - perhaps
[sterling]6,600 in an elderly population.
So it looks as if there is a balance between spending money on supplements or
spending money on treating broken hips. But that is just the cost basis. Most elderly
people with broken hips have a much reduced quality of life, over and above the
trauma and hurt. They rarely get back to the same degree of independent living as
they enjoyed before they fell and broke their hip. Where there is an identifiable
population at risk, purchasers may want to do their own computations for benefit in
their own area.
Who is most at risk?
Of patients admitted with hip fracture, 87% are over the age of 65, and 82% of these
are women.
Risk factors for osteoporosis are many, and include :
genetic predisposition
poor nutrition in childhood and adolescence
early age of onset of menopause
decreased exposure to sunshine and low vitamin D intake
low dietary calcium
alcohol and cigarette use
caffeine consumption
low weight
lack of regular exercise
References
MC Chapuy, ME Arlot, F Debouef etc. Vitamin D3 and calcium to prevent hip
fractures in elderly women. New England Journal of Medicine 1992 327: 1637-42.
MC Chapuy, ME Arlot, PD Delmas, PJ Meunier. Effect of calcium and
cholecalciferol treatment for three years on hip fractures in elderly women.
WJ Gillespie, DA Henry, DL O'Connell, J Robertson. Vitamin D and Vitamin D
analogues in the prevention of fractures in involutional and post-menopausal
osteoporosis. The Cochrane Library 1997, issue 1.
Bandolier 25
, March 1996.
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