Cholesterol and Drugs

How can high cholesterol be controlled?

High cholesterol affects many people throughout the world. High cholesterol levels can greatly increase the risk of heart disease, including potentially fatal heart attacks. Exercise, weight loss, and a diet low in cholesterol and saturated fats can help lower cholesterol levels. However, when these measures fail, cholesterol-lowering medications are usually needed. In this slideshow we'll discuss cholesterol basics, and review the classes of drugs prescribed to lower cholesterol.

What is cholesterol?

Cholesterol is a waxy, fat-like substance that your body needs to function normally. The cholesterol in a person's blood originates from two major sources; the diet and the liver. Dietary cholesterol comes primarily from meat, poultry, fish, and dairy products. Cholesterol is naturally present in cell walls or membranes everywhere in the body, including the brain, nerves, muscles, skin, liver, intestines, and heart. Your body uses cholesterol to produce many hormones, vitamin D, and the bile acids that help to digest fat. It takes only a small amount of cholesterol in the blood to meet these needs. If you have too much cholesterol in your bloodstream, the excess may be deposited in arteries, including the coronary (heart) arteries, where it contributes to the narrowing and blockages that cause the signs and symptoms of heart disease.

 

What are LDL cholesterol, HDL cholesterol, and triglycerides?

Cholesterol is carried in the blood as particles of differing sizes and densities along with lipoproteins, proteins that associate with cholesterol. Cholesterol carried in particles of low density (LDL cholesterol) is referred to as the "bad" cholesterol because elevated levels of LDL cholesterol are associated with an increased risk of coronary heart disease. LDL lipoprotein deposits cholesterol on the artery walls, causing the formation of a hard, thick, substance called cholesterol plaque. Over time, cholesterol plaque causes thickening of the arterial walls and narrowing of the arteries, a process called atherosclerosis.

Cholesterol carried in particles of high density (HDL cholesterol) is referred to as the "good cholesterol" because HDL cholesterol particles prevent atherosclerosis by extracting cholesterol from the arterial walls and disposing of it through the liver. Thus, high levels of LDL cholesterol and low levels of HDL cholesterol (high LDL/HDL ratios) are risk factors for atherosclerosis, while low levels of LDL cholesterol and high levels of HDL cholesterol (low LDL/HDL ratios) are desirable.

Triglyceride is a fatty substance composed of three fatty acids. Like cholesterol, triglyceride in the blood comes from the diet or liver.

What types of cholesterol drugs are available?

Medications can be used to lower blood levels of undesirable lipids such as LDL cholesterol and triglycerides, and increase blood levels of desirable lipids such as HDL cholesterol. Several classes of medications are available in the United States, including statins (HMG CoA reductase inhibitors), nicotinic acid (niacin), fibric acid derivatives (fibrates), bile acid sequestrants, and cholesterol absorption inhibitors. Some of these medications can also be combined to more aggressively lower LDL, as well as lower LDL and increase HDL cholesterol levels at the same time.

What are statins?

Statins are a class of drugs that lower the level of cholesterol in the blood by reducing the production of cholesterol by the liver. Statins block the enzyme in the liver that controls the production of cholesterol. Most patients are placed on statins because of high levels of cholesterol; however, statins are also used for preventing and treating atherosclerosis that causes chest pain, heart attacks, strokes, and intermittent claudication in individuals who have or are at risk for atherosclerosis.

Risk factors for atherosclerosis include:

• abnormally elevated cholesterol levels,
• a family history of heart attacks (particularly at a young age),
• increasing age,
• diabetes, and
• high blood pressure.

The next several slides are examples of statins currently prescribed to lower cholesterol.

atorvastatin (Lipitor)

Drug Class: Statins
Prescription: Yes
Generic: No
Preparations: Tablets of 10, 20, 40, and 80 mg.

Prescribed for: Atorvastatin (Lipitor) is used for the treatment of elevated total cholesterol, LDL, triglycerides, and to elevate HDL cholesterol. The effectiveness of atorvastatin (Lipitor) in lowering cholesterol is dose-related, meaning that higher doses reduce cholesterol more.

Side effects: Atorvastatin (Lipitor) is generally well-tolerated. Minor side effects include constipation, diarrhea, fatigue, gas, heartburn, and headache. Atorvastatin (Lipitor) may cause liver and muscle damage.

rosuvastatin (Crestor)

Drug Class: Statins
Prescription: Yes
Generic: No
Preparations: Tablets of 5, 10, 20, and 40 mg.

Prescribed for: Rosuvastatin (Crestor) is used for the reduction of blood total cholesterol, LDL cholesterol and triglyceride levels, and to increase HDL cholesterol levels.

Side effects: The most common side effects of rosuvastatin (Crestor) are headache, nausea, vomiting, diarrhea, and muscle pain. The most serious side effects are liver failure, muscle breakdown (rhabdomyolysis) and kidney failure

simvastatin (Zocor)

Drug Class: Statins
Prescription: Yes
Generic: Yes
Preparations: Tablets of 5, 10, 20, 40, and 80 mg.

Prescribed for: Simvastatin (Zocor) is used for reducing total cholesterol, LDL cholesterol, and triglycerides, and for increasing HDL cholesterol. In patients with coronary heart disease, diabetes, peripheral vessel disease, or history of stroke or other cerebrovascular disease.

Side effects: The most common side effects of simvastatin (Zocor) are headache, nausea, vomiting, diarrhea, abdominal pain, muscle pain, and abnormal liver tests. Hypersensitivity reactions have also been reported. The most serious potential side effects are liver damage and muscle inflammation or breakdown.

pravastatin (Pravachol)

Drug Class: Statins
Prescription: Yes
Generic: Yes
Preparations: Tablets of 10, 20, 40, and 80 mg.

Prescribed for: Pravastatin (Pravachol) is used for the reduction of total and LDL cholesterol as well as triglycerides, and to increase HDL cholesterol. It has been suggested that pravastatin may reduce the occurrence of heart attacks, strokes, and death caused by coronary artery disease.

Side Effects: The most common side effects of pravastatin (Pravachol) are headache, nausea, vomiting, diarrhea, muscle pain, and abnormal liver tests. The most serious potential side effects are liver damage and muscle inflammation or breakdown.

lovastatin (Mevacor)

Drug Class: Statins
Prescription: Yes
Generic: Yes
Preparations: Tablets of 10, 20, and 40 mg.

Prescribed for: Lovastatin (Mevacor) is used to treat high LDL cholesterol. Effectiveness of the medication in lowering cholesterol is dose-related. Blood cholesterol determinations are performed in regular intervals during treatment so that dosage adjustments can be made. A reduction in LDL cholesterol level can be seen two weeks after starting therapy.

Side Effects: Side effects of lovastatin (Mevacor) are rare. Minor side effects include constipation, diarrhea, gas, heartburn, headache, and insomnia. Major side effects include abdominal pain or cramps, blurred vision, dizziness, itching, muscle pain or cramps, rash, or yellowing of the skin or eyes

fluvastatin (Lescol)

Drug Class: Statins
Prescription: Yes
Generic: No
Preparations: Tablets of 20 and 40 mg.

Prescribed for: Fluvastatin (Lescol) is used to treat high LDL cholesterol. Effectiveness of the medication in lowering cholesterol is dose-related. Blood cholesterol determinations are performed in regular intervals during treatment so that dosage adjustments can be made.

Side effects: Side effects of fluvastatin (Lescol) are rare. Minor side effects include constipation, diarrhea, gas, heartburn, headache, and insomnia. Major side effects include abdominal pain or cramps, blurred vision, dizziness, itching, muscle pain or cramps, rash, or yellowing of the skin or eyes.

What are fibric acid derivatives (fibrates)?

Fibrates are effective medications that lower blood triglyceride levels. Fibrates lower blood triglyceride levels by inhibiting production in the liver of VLDL (particles in the blood that carry triglycerides and lipoproteins), and by speeding up the removal of triglycerides from the blood.

Fibrates also are modestly effective in increasing blood HDL cholesterol levels; however, fibrates are not effective in lowering LDL cholesterol. Doctors may consider combining a fibrate with a statin. Such a combination will not only lower the LDL cholesterol, but will also lower blood triglycerides and increase HDL cholesterol levels.

Fibrates also have been used alone to prevent heart attacks in patients with elevated blood triglycerides and low HDL cholesterol levels.

fenofibrate (Tricor)

Drug Class: Fibrates
Prescription: Yes
Generic: No
Preparations: Tablets of 48 and 145 mg.

Prescribed for: Fenofibrate (Tricor) is used along with a non-drug program (including diet changes) to treat elevated cholesterol and triglyceride levels.

Side effects: Common side effects of fenofibrate (Tricor) include upset stomach, constipation, headache, dizziness or trouble sleeping. Muscle damage may occur, and muscle pain, tenderness, weakness and fever should be reported promptly to the responsible physician. Decreased sexual drive, yellowing of the eyes or skin (jaundice), and stomach pain may occur and also should be reported.

gemfibrozil (Lopid)

Drug Class: Fibrates
Prescription: Yes
Generic: No
Preparations: Tablet of 600 mg.

Prescribed for: Gemfibrozil (Lopid) is used for persons with either low HDL cholesterol and/or high triglyceride concentrations to reduce the risk of heart attacks. It also is used in persons with very high triglyceride levels that may cause pancreatitis (inflammation of the pancreas).

Side effects: Side effects of gemfibrozil (Lopid) include upset stomach (1 in 5 patients), diarrhea (1 in 14 patients), tiredness (1 in 30 patients) and nausea or vomiting (1 in 40 patients). Additional patients may experience dizziness, tiredness, tingling in the extremities, headache, decreased sexual drive, impotence, depression, or blurred vision. Less common side effects are muscle aches, pains, weakness or tenderness.

What are bile acid sequestrants?

Bile acid sequestrants bind bile acids in the intestine and cause more of the bile acids to be excreted in the stool. This reduces the amount of bile acids returning to the liver and forces the liver to produce more bile acids to replace the bile acids lost in the stool. In order to produce more bile acids, the liver converts more cholesterol into bile acids, which lowers the level of cholesterol in the blood.

Bile acid sequestrants have modest LDL cholesterol-lowering effects. However, bile acid sequestrants are most useful in combination with a statin or niacin to aggressively lower LDL cholesterol levels. The statin-bile acid sequestrant combination can lower LDL cholesterol levels by approximately 50%, lower than a statin alone. A statin-niacin combination also can substantially elevate HDL cholesterol.

colesevelam (Welchol)

Drug Class: Bile acid sequestrants
Prescription: Yes
Generic: No
Preparations: Tablet of 625 mg.

Prescribed for: Colesevelam (Welchol) is used to treat high blood cholesterol levels, especially high levels of LDL cholesterol. It does not lower cholesterol as much as the statin class of drugs, but when used in combination with a statin, it lowers cholesterol levels further than the statin alone.

Colesevelam (Welchol) also is used in combination with other drugs for treating type 2 diabetes such as metformin (Glucophage), sulfonylureas, or insulin to further lower blood sugar levels.

Side effects: Colesevelam (Welchol) usually is well-tolerated. Patients may experience constipation, upset stomach, indigestion, headache, stomach pain, or diarrhea.

colestipol (Colestid)

Drug Class: Bile acid sequestrants
Prescription: Yes
Generic: No
Preparations: Tablet of 1 gm. Granules in 5gm packets or bulk.

Prescribed for: Colestipol (Colestid) is used for the treatment of high cholesterol in conjunction with dietary control; for the treatment of diarrhea due to increased intestinal bile acids after some types of surgery; for the treatment of itching associated with partial obstruction to the flow of bile due to liver disease.

Side effects: Side effects of colestipol (Colestid) include constipation, stomach upset, heartburn, belching, gas, nausea, loss of appetite, aggravated hemorrhoids, change of taste, headache, or itching. If patients experience unusual bruising or bleeding, severe stomach aches, or vomiting they should notify their physicians.

cholestyramine (Questran)

Drug Class: Bile acid sequestrants
Prescription: Yes
Generic: Yes
Preparations: Powder

Prescribed for: Cholestyramine (Questran) is used for reducing cholesterol levels in the blood, to relieve the itching of liver and biliary disease, and to treat overdoses of digoxin or thyroid hormone.

Side effects: The most common side effects are constipation, abdominal pain, bloating, vomiting, diarrhea, weight loss, and excessive passage of gas (flatulence). Long-term use of cholestyramine may cause a deficiency of vitamins A, D, E, and K.

What is nicotinic acid (vitamin B3 or niacin)?

Nicotinic acid (vitamin B3 or niacin) is a B vitamin. An average American diet contains 15-30 mg of niacin per day. However, in treating blood cholesterol and triglyceride disorders, high doses (1-3 grams a day) of nicotinic acid are necessary. Nicotinic acid is available in several preparations. Prescription nicotinic acid includes immediate release niacin or sustained release niacin. Over-the-counter (OTC) nicotinic acid is available as sustained release niacin. OTC preparations are not federally regulated, and some OTC preparations may have no active ingredient and are ineffective in lowering LDL or raising HDL cholesterol.

Nicotinic acid is most effective in increasing HDL cholesterol, and modestly effective in lowering LDL cholesterol and triglyceride levels. Used alone, it can raise HDL cholesterol levels by 30% or more. However, it is not as effective as a statin in lowering LDL cholesterol

niacin, nicotinic acid, vitamin B3
(Niacor, Niaspan, Slo-Niacin)

Prescription: Yes and over-the-counter (OTC)
Generic: Yes
Preparations: Tablets of 50, 100, 250, 500 and 750 mg. Capsules of 125, 250, 400, 500, 750 and 1000 mg.

Prescribed for: Nicotinic acid (vitamin B3 or niacin) is used for treating niacin deficiency and elevated blood cholesterol and/or triglyceride levels and for increasing HDL cholesterol.

Side effects: The most common side effects of nicotinic acid (vitamin B3 or niacin) are stomach upset, flushing, headache, itching and tingling sensations of the extremities. Rare cases of liver failure or muscle injury have occurred from the use of nicotinic acid.

What are cholesterol absorption inhibitors?

This relatively new class of cholesterol-lowering medication works by preventing the absorption of cholesterol from the intestine. Selective cholesterol absorption inhibitors are most effective at lowering the LDL (bad) cholesterol but may also have modest effects on lowering triglycerides (blood fats), and raising HDL (good) cholesterol.

ezetimibe (Zetia)

Drug Class: Cholesterol absorption inhibitors
Prescription: Yes
Generic: No
Preparations: Tablets of 10 mg.

Prescribed for: Ezetimibe (Zetia) lowers blood cholesterol by reducing the absorption of cholesterol from the intestine. Used in combination with statins, it reduces levels of total cholesterol, LDL cholesterol, and triglycerides. It also may raise HDL cholesterol. Combining ezetimibe with a statin is more effective than either drug alone.

Side effects: Ezetimibe (Zetia) usually is well-tolerated. Diarrhea, abdominal pain, back pain, joint pain, and sinusitis were the most commonly reported side effects, occurring in one in every 25 to 30 patients. Hypersensitivity reactions, including angioedema (swelling of the skin and underlying tissues of the head and neck that can be life-threatening) and skin rash occur rarely. Nausea, pancreatitis, muscle damage (myopathy or rhabdomyolysis), and hepatitis have been reported.

Combining drugs to fight high cholesterol.

As noted on the previous slides, some medications are primarily useful in lowering LDL cholesterol, others in lowering triglycerides, and some in elevating HDL cholesterol. Doctors may also prescribe two medications from two different drug classes to more aggressively lower LDL, as well as increase HDL cholesterol levels at the same time.

ezetimibe/simvastatin (Vytorin)

Prescription: Yes
Generic: No
Preparations: Tablets of 10/10, 10/20, 10/40, 10/80 mg. (ezetimibe/simvastatin)

Prescribed for: Ezetimibe/simvastatin (Vytorin) is a combination of ezetimibe (Zetia) and simvastatin (Zocor) that is used for treating high levels of cholesterol in the blood. Vytorin reduces total cholesterol and LDL cholesterol while it increases HDL cholesterol.

Side effects: The most common side effects of ezetimibe/simvastatin (Vytorin) are headache, nausea, vomiting, diarrhea, muscle pain, and abnormal liver tests. Hypersensitivity reactions have also been reported. The most serious potential side effects are liver damage and muscle inflammation or breakdown.

niacin and lovastatin (Advicor)

Prescription: Yes
Generic: No
Preparations: Tablet of 500/20 and 1000/20 mg (niacin/lovastatin).

Prescribed for: Niacin and lovastatin (Advicor) is used for treating elevated blood levels of total cholesterol, LDL cholesterol, and triglycerides, and for raising low levels of HDL cholesterol.

Side effects: Please refer to the individual slides for niacin and lovastatin.

C

holesterol-altering drugs overview

This chart provides a textual overview of the various cholesterol drugs discussed in this slideshow. It lists each of the medication classes, examples within each class, and their areas of beneficial effectiveness.

What is caffeine?

There are few people who are not aware of the stimulating effect that caffeine provides. We have a choice and choose caffeinated beverages for a reason. Caffeine is considered the most commonly used psychoactive drug in the world. Approximately 80% of the world's population consumes it on a daily basis, and continuous research is being done on its health benefits and consequences.

Caffeine is the common name for 1,3,7-trimethylxanthine. When purified, caffeine produces an intensely bitter white powder that provides a distinctive taste in soft drinks. The word "caffeine" came from the German word kaffee and the French word café, each meaning coffee. After ingesting caffeine, it is completely absorbed within 30 to 45 minutes, and its effects substantially diminish within about three hours. It is eventually excreted so there is no accumulation in the body. Caffeine has been shown to affect mood, stamina, the cerebral vascular system, and gastric and colonic activity. But caffeine may not be for everyone. This article will discuss the health benefits and consequences of caffeine.

What are the sources of caffeine?

Caffeine is naturally found in certain leaves, seeds, and fruits of over 60 plants worldwide. The most common sources in our diet are coffee, tea leaves, cocoa beans, cola, and energy drinks. Caffeine can also be produced synthetically and added to food, beverages, supplements, and medications. Product labels are required to list caffeine in the ingredients but are not required to list the actual amounts of the substance. A low to moderate intake is 130 to 300 mg of caffeine per day, while heavy caffeine consumption corresponds to more than 6,000 mg/day. It is estimated that the average daily caffeine consumption among Americans is about 280 mg/day, while 20% to 30% consume more than 600 mg daily. The caffeine content in some common sources of caffeine are listed below:

Sources of Caffeine	Caffeine Content
Coffee
Plain, brewed 8 oz	135 mg
Instant 8 oz	95 mg
Espresso 1 oz	30-50 mg
Plain, decaffeinated 8 oz	5 mg
Tea
Green tea 8 oz	25-40 mg
Black tea 8 oz	40-70 mg
Soft Drinks
Coca-Cola Classic 12 oz	34.5 mg
Diet Coke 12 oz	46.5 mg
Dr. Pepper 12 oz	42 mg
Mountain Dew 12 oz	55.5 mg
Pepsi-Cola 12 oz	37.5 mg
Sunkist Orange 12 oz	42 mg
Energy Drink
Full Throttle, 16 oz	144 mg
Red Bull, 8.5 oz	80 mg
SoBe No Fear	158 mg
Chocolates or Candies
Candy, milk chocolate 1 bar (1.5 oz)	9 mg
Candy, sweet chocolate 1 bar (1.45 oz)	27 mg
Cocoa mix, powder 3 tsp	5 mg
Puddings, chocolate, ready-to-eat 4 oz	9 mg
Medicine: Over the Counter
Excedrin	65 mg
Bayer Select Maximum Strength	65.4 mg
Midol Menstrual Maximum Strength	60 mg
NoDoz 100 mg	32.4 mg
Pain Reliever Tablets	65 mg
Vivarin	200 mg

There are many products that may contain caffeine without your awareness. Be sure to read the label to see if caffeine is listed among the ingredients.

Caffeine (cont.)

Is caffeine addictive?

Have you ever said that you can't function until your morning cup of coffee? Do you find yourself reaching for caffeinated coffee, tea, or soda when you are feeling lethargic? Could it be that you are addicted to caffeine? That all depends on who you ask. Whether we consume caffeine for pleasure or purpose is a controversial topic. Those opposed to caffeine being addictive claim that we consume it for the pleasure of the product, while those who believe that it is addictive claim that we consume it for the purpose of satisfying our craving for it.

Psychiatric diagnoses are categorized by a manual published by the American Psychiatric Association called the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). This manual covers all mental-health disorders for both children and adults. The DSM-IV has a proposed diagnosis of caffeine withdrawal, instead of an official diagnosis, to encourage further research on the range and specificity of caffeine-withdrawal symptoms. A review and analysis of the effects of caffeine abstinence in humans claims that the withdrawal symptoms experienced are proof of physical dependence. These symptoms includeheadache, tiredness/fatigue, decreased energy/activeness, decreased alertness/attentiveness, drowsiness/sleepiness, decreased contentedness/well-being, depressed mood, difficulty concentrating, irritability, and felling muzzy/foggy/not clearheaded. The study also found that the onset of withdrawal symptoms typically begins 12 to 24 hours after abstinence, with the peak intensity occurring at 20 to 51 hours. The duration of withdrawal symptoms ranged from two to nine days. This is a considerable amount of time that makes it easy to understand why people would have a hard time omitting caffeine from their diet. It was recommended that further research be done to determine how vulnerability to caffeine withdrawal is affected by gender, genetics, personality, behavioral conditioning, drug abuse histories, and other factors.

As compelling as the research in favor of caffeine being addictive is, there is equally compelling evidence that it is not addictive. It is argued that the pleasurable aroma, taste, and social aspects of coffee are the reasons for consumption. Research has shown that the desire to repeatedly use caffeine is primarily found in heavy caffeine consumers who also had histories of alcohol or drug abuse, and not in moderate consumers. While there is some agreement about the occurrence of withdrawal symptoms, there is disagreement about any form of addiction to caffeine. An addiction can be demonstrated by the irresistibility of regular consumption and problems created from its consumption. Caffeinated products are said to be consumed by habit, not need, and do not pose any harm to society.

The definitive answer to the question of whether caffeine is addictive is still unknown. Research is under way to clarify the issue. For anyone looking to decrease or cut out caffeine, experts all recommend doing so slowly. Stopping abruptly can result in unpleasant side effects.

Is caffeine a diuretic?

Caffeine has been considered a diuretic by experts and consumers for years. Some people believe that drinking caffeinated beverages will cause them to lose fluids so they can't be counted as part of their daily intake. Others say that caffeinated beverages do not increase fluid losses. The best way to flush out the truth is to examine the research.

Each day our body has a need for water. We lose water through respiration, skin, renal, and gastrointestinal tract losses. Our intake of water comes from liquids and foods. We need to maintain an adequate water balance for our bodies to function properly. Factors such as age, activity level, health, diet, and environment can affect our water balance.

Some research has shown that caffeine intake can also affect our fluid balance. In one study, 12 caffeine consumers were told to abstain from caffeine for five days and were then given 642 mg of caffeine in the form of coffee. Their urine output increased when given the caffeine. Another study done on eight men tested the effect of 45, 90, 180, or 360 mg of caffeine on urine volume. An increase in urine volume was seen only at the 360-mg dose of caffeine. One limitation to these studies is that they did not evaluate the impact of caffeine when consumed on a regular basis. A onetime dose may affect the body differently than daily consumption.

Back in 1928, caffeine was shown to have no significant impact on urinary output. Subsequent studies have shown that caffeine-containing beverages did not impact urinary output any differently than other beverages. Based on this, the Institute of Medicine recommends that "unless additional evidence becomes available indicating cumulative total water deficits in individuals with habitual intakes of significant amounts of caffeine, caffeinated beverages appear to contribute to the daily total water intake similar to that contributed by noncaffeinated beverages."

This doesn't mean that caffeine does not increase your need to urinate. Your reaction can depend on the amount that you consume, the type of product, and your tolerance level. If you have urinary incontinence, you may experience a greater "urgency" to urinate after consuming a caffeinated beverage. You will need to monitor your reaction and tolerance to caffeine to determine how you are affected. Water is still the recommended choice for optimal hydration, so be sure to include it as part of your daily fluid consumption.

Does caffeine cause heart disease?

With the high prevalence of heart disease, links between lifestyle factors, such as diet and physical activity, are undergoing extensive research. The original research into caffeine's role in this epidemic resulted in conflicting answers. Some evidence suggests an elevation in stress hormones from caffeine consumption that could pose a cardiovascular risk, but recent research has shown no relationship between caffeine ingestion and heart disease. In fact, studies have actually shown a protective effect against heart disease with habitual intake of caffeinated beverages in the elderlypopulation. The reason for the discrepancy may be due to the kind of beverage being consumed. Studies have shown that coffee and tea were not associated with increases in blood pressure or arrhythmias, while soft drinks were. Research also showed that decaffeinated coffee and tea did not provide the same benefits as the caffeinated versions. The well-respected Framingham Heart Study examined all potential links between caffeine intake and cardiovascular disease and found no harmful effects from drinking coffee. There can, however, be exceptions to this. People react differently to caffeine, and some may experience elevations in blood pressure or arrhythmias. The blood pressure elevations are said to be short-lived, lasting no more than several hours and are comparable to modest elevations experienced climbing a flight of stairs. It's always best to check with your physician if you are experiencing any side effects.

Does caffeine cause bone loss?

Too much of a good thing could be a problem for caffeine consumers. Evidence suggests that high caffeine intake may accelerate bone loss. One study found that elderly postmenopausal women who consumed more than 300 mg per day of caffeine lost more bone in the spine than women who consumed less than 300 mg per day. However, coffee and tea drinkers may be able to counteract this negative effect by adding milk to their beverage. The consumption of cola has also been shown to be associated with lower bone mineral density. While these studies were compelling, more evidence is needed to make a definitive decision about the role of caffeine and osteoporosis.

Does caffeine help with weight loss?

The weight-loss industry is estimated to be a $50 billion a year industry. Many people are looking for a way to get their piece of the money-making pie without a lot of credibility behind what they are promoting. The supplement industry is constantly promoting a new product to enhance weight loss by increasing satiety or burning fat. The claims are convincing, but the research backing many products is often lacking. To make matters worse, supplements often contain combinations of ingredients in the hopes of enhancing each one's effect without safety or efficacy tests. Caffeine is one of the ingredients now being included in many of the weight-loss supplements. It's added for its energy enhancement, appetite suppressant, and "fat-burning" properties.

The scientific evidence about caffeine as a weight-control agent is mixed. In a study done to monitor the impact of a green tea-caffeine combination on weight loss and maintenance, participants were divided into those who consume low levels of caffeine (<300 mg/day) and high-caffeine consumers (>300 mg/day). Weight loss was significantly higher in the high-caffeine consumption group, but weight maintenance was higher in the low-caffeine consumption group. The conclusion was that the caffeine was related to greater weight loss, higher thermogenesis, and fat oxidation, while the tea was responsible for the greater weight maintenance. Other studies have stated that caffeine actually contributes to weight gain by increasing stress hormones. It appears that caffeine's role in weight loss is as inconclusive as the efficacy of the majority of weight-loss supplements on the market.

Is caffeine safe during pregnancy?

There is no disputing the importance of proper nutrition during pregnancy. There is some dispute about the safety of caffeine during this time. One concern is that caffeine may lead to miscarriages. In a study following 431 pregnant women, no relationship between caffeine consumption up to 300 mg/day and adverse pregnancy outcomes was found. Another study examined the relationship between caffeine consumption and spontaneous abortions in over 5,000 women and found no association.

Research has also shown no clear relationship between caffeine intake and fertility andbirth defects. While the evidence appears to show no risk for pregnant women, the recommendations are to limit caffeine intake. It is difficult to accurately test the effects of very high intakes of caffeine without risking the health of the mother and child. The majority of the subjects in the studies were consuming small to moderate amounts of caffeine. The American College of Obstetricians and Gynecologists recommends a caffeine limit of the equivalent of 1 to 2 cups of coffee per day during pregnancy.

Should caffeine be consumed by children?

With the increased popularity of coffee shops, a new generation of caffeine consumers was born. Children are being exposed to caffeine from soft drinks, coffee, tea, energy drinks, ice cream, caffeinated water, chocolate, and medications on a daily basis. Could this trend be harming children?

The Center for Science in the Public Interest (CSPI), a consumer advocacy group, wants the FDA to require labels on caffeine-containing products that list the number of grams of caffeine they contain along with the warning that caffeine is a mild stimulant and not appropriate for children. A great deal of the problem with caffeine is the fact that caffeinated soft drinks often replace more nutritious drinks like milk. The trend is that milk consumption clearly shows a decline over time, while soft drink consumption has risen. Vending machines were added to some schools which exposed children of all ages to soft drinks.

The Centers for Disease Control and Prevention's School Health Policies and Programs Study (SHPPS) 2000 survey concluded that 43% of elementary schools, 89.4% of middle/junior high, and 98.2% of senior high schools had either a vending machine or a school store, canteen, or snack bar where students could purchase foods or beverages. A study done by CSPI found that of the drinks sold in the 13,650 vending-machine slots surveyed, 70% were sugary drinks such as soda, juice drinks with less than 50% juice, iced tea, and "sports" drinks. Of the sodas, only 14% were diet, and only 12% of the drinks available were water. Just 5% of drink options were milk but of those, most (57%) were high-fat, whole, or 2% milk. Fortunately, this problem has gained a great deal of recognition and some states have now enacted legislation to replace existing food and drinks of minimal nutritional value for healthier options or to restrict student access to the machines.

The effect of caffeine on children's moods and behavior is another concern. In a studydone by the National Institute of Mental Health, 8- to 13-year-olds who regularly consumed high doses of caffeine were judged to be more restless by teachers, and one-third were hyperactive enough to meet the criteria for attention deficit disorder with hyperactivity (ADHD). A Stanford study of fifth- and sixth-graders deprived of daily caffeine reported having symptoms including trouble thinking clearly, not feeling energetic, and getting angry. These symptoms were even reported by children who typically consume 28 mg of caffeine a day. The research in this area is somewhat limited, but the studies that have been conducted are compelling enough to warrant restricting caffeine intake in children to as little as possible. If there is no need for caffeine, why take the risk and allow children to consume it?

How much fluid do we need?

Anyone who has ever been on a diet will tell you that you are supposed to drink at least 8 cups of water a day. Everyone knows this, but finding the evidence to support it is another story. In 2004, the Food and Nutrition Board established recommendations on the intake of water. The recommendations were set based on the necessary amount needed to maintain health and reduce chronic disease risk:

• The vast majority of healthy people adequately meet their daily hydration needs by letting thirst be their guide.
• The report did not specify exact requirements for water, but set general recommendations for women at approximately 2.7 L (91 oz) of total water-from all beverages and foods-each day, and men an average of approximately 3.7 L (125 oz daily) of total water.
• The panel did not set an upper level for water.
• About 80% of people's total water intake comes from drinking water and beverages—including caffeinated beverages—and the other 20% is derived from food.
• Prolonged physical activity and heat exposure will increase water losses and therefore may raise daily fluid needs, although it is important to note that excessive amounts of fluid can be life-threatening. Acute water toxicity has been reported due to rapid consumption of large quantities of fluids that greatly exceeded the kidney's maximal excretion rate of approximately 0.7 to 1.0 L/hour.

The report allows all fluids to be counted into your total intake, so people began eliminating water from their diet in favor of other liquids. However, the recommendations were not intended to reduce water consumption. Water should be your primary source of fluid. Our bodies are made up of over 60% water, not coffee, tea, juice, or soda. Caffeine is a treat that will have health consequences when consumed in excessive amounts and is not safe for everyone. Set limits on the treats that you allow yourself, and be sure to give your body what it needs in adequate amounts. It's the only body that you have.

Diabetes Pictures, Learn the Warning Signs

Type 2 Diabetes: What Is It?

Diabetes is a chronic condition that thwarts the body's ability to convert sugar into energy. This allows sugar levels to build up in the blood, which can lead to heart disease, blindness, and other serious complications. Type 2 diabetes strikes people of all ages, and early symptoms are subtle. In fact, a third of people with type 2 diabetes don't know they have it. Learn the warning signs in this slideshow.

Warning Sign: Thirst

One of the first symptoms of type 2 diabetes may be an increase in thirst. This is often accompanied by additional problems, including dry mouth, increased appetite, frequent urination – sometimes as often as every hour -- and unusual weight loss or gain.

Warning Sign: Headaches

As blood sugar levels become more abnormal, additional symptoms may include headaches, blurred vision, and fatigue

Warning Sign: Infections

In most cases, type 2 diabetes is not discovered until it takes a noticeable toll on health. One red flag is troubling infections, such as:

• Cuts or sores that are slow to heal.
• Frequent yeast infections.
• Itchy skin, especially in the groin area.

Risk Factors You Can Control

Your habits and lifestyle can affect your odds of developing type 2 diabetes. Factors that boost your risk include:

• Being overweight, defined as a body mass index (BMI) over 25.
• Abnormal cholesterol and blood fats, such as good cholesterol (HDL) lower than 35 mg/dL or a triglyceride level over 250 mg/dL.
• High blood pressure, greater than 140 /90 in adults.
• Sedentary lifestyle.

Risk Factors You Can't Control

Other risk factors are out of your control, including:

• Race or ethnicity: Hispanics, blacks, Native Americans, and Asians have a higher than average risk.
• Family history of diabetes: Having a parent or sibling with diabetes boosts your risk.
• Age: Being 45 and older increases your risk of type 2 diabetes.

The more risk factors your have, the greater your odds of developing type 2 diabetes.

Type 2 Diabetes in Children

Although older people have a higher risk of getting type 2 diabetes, the condition is striking more young people. A third of American children born in 2000 will develop type 2 diabetes, according to the CDC. The leading risk factor for kids is being overweight, often connected with an unhealthy diet and lack of physical activity. Once children are overweight, their chances of developing type 2 diabetes more than doubles.

Diagnosing Type 2 Diabetes

There's no need for guesswork in diagnosing type 2 diabetes. A simple blood test, called a fasting plasma glucose test, does the trick. The test measures the level of sugar in your blood after you have been fasting for at least 8 hours. Normal fasting blood glucose is between 70 and 100 mg/dL. If two separate blood tests show this level is greater than or equal to 126 mg/dL, type 2 diabetes is diagnosed.

Converting Glucose to Energy

In healthy people, after a meal, food is broken down into a sugar called glucose, which is carried by the blood to cells throughout the body. Cells use the hormone insulin, made in the pancreas, to help them process blood glucose into energy. People develop type 2 diabetes because the cells in the muscles, liver, and fat do not use insulin properly.

Long-Term Damage: Arteries

Over time, untreated type 2 diabetes can damage many of the body's systems. Two out of three people with diabetes die of heart disease. Having diabetes also puts you at risk for stroke. People with diabetes are likely to develop plaque in their arteries, which reduces blood flow and increases the risk of clots. This raises the risk of heart attack and stroke

Long-Term Damage: Kidneys

The longer you have diabetes, the greater the risk of developing kidney disease or kidney failure. Patients with kidney failure must get a kidney transplant or rely on dialysis to survive.

Long-Term Damage: Eyes

High blood sugar can damage the tiny blood vessels that bring oxygen and nutrients to the retina, a critical part of the eye. This is known as diabetic retinopathy, and it can cause progressive, irreversible vision loss. It is the leading cause of blindness in people between the ages of 20 and 60. Pools of blood, or hemorrhages, on the retina of an eye are visible in this image.

Long-Term Damage: Feet

People with diabetes often experience nerve damage that can make it more difficult to feel their feet. At the same time, hardening of the arteries results in poor blood flow to the feet. Foot sores and gangrene can occur. In severe cases, the foot or leg must be amputated.

Managing Diabetes: Diet

Fortunately, people with type 2 diabetes can significantly reduce the risk of damage to the heart, kidneys, eyes, and feet. The key is controlling blood sugar levels by changing diet. People with type 2 diabetes should carefully monitor carbohydrate consumption, as well as total fat and protein intake, and reduce calories.

Managing Diabetes: Exercise

Moderate exercise, such as strength training or walking, improves the body's use of insulin and can lower blood sugar levels in people with type 2 diabetes. Being active also helps reduce body fat, lower blood pressure, and protect against heart disease. People with type 2 diabetes should try to get 30 minutes of moderate exercise on most days of the week.

Managing Diabetes: Medication

When people with type 2 diabetes are unable to control blood sugar sufficiently with diet and exercise, medication can help. There are many types of diabetes pills available, and they are often used in combination. Some work by stimulating the pancreas to make more insulin, and others improve the effectiveness of insulin or block the digestion of starches.

Managing Diabetes: Insulin

Many people with type 2 diabetes eventually develop "beta-cell failure." This means the cells in the pancreas no longer produce insulin in response to high blood sugar levels. In this case, insulin therapy – injections or an insulin pump – must become part of the daily routine.

Preventing Type 2 Diabetes

One of the most astonishing things about type 2 diabetes is that such a life-altering condition is often preventable. To lower your risk, follow the same guidelines for warding off heart disease:

• Eat a healthy diet
• Exercise for 30 minutes 5 days a week
• Maintain a healthy weight
• Talk to your doctor about being screened for prediabetes

In people with pre-diabetes, lifestyle changes and medication can help prevent the progression to type 2 diabetes.