Sherry Boschert

A newly identified parvovirus appears to cause lower respiratory tract infections in children, a team of scientists in Sweden and Singapore reported.

They detected the virus—provisionally named human bocavirus (HBoV)—through a rapid new system for large-scale molecular virus screening of clinical samples without the need for cultures and with minimal hands-on effort. Their method should make it feasible to systematically explore all viruses that affect humans, including unidentified ones, reported Tobias Allander, M.D., of Karolinska University Hospital, Stockholm, and his associates (Proc. Natl. Acad. Sci. USA 2005;102:12891–6).

To assess HBoV's clinical effects, the investigators screened culture-negative nasopharyngeal aspirate samples from 266 pediatric patients and 112 adults seen in clinics. Seven samples from infants and children were positive for HBoV. A subsequent retrospective study of all 540 aspirates available from the pediatric infectious diseases ward at the hospital found HBoV in 17 patients (3%), and 14 of these had no other viruses present. HBoV is the likely cause of the respiratory distress and fever in these patients, the investigators concluded.

Seven of the 14 patients underwent chest x-ray, and results showed interstitial bilateral infiltrates in 6 patients.

Approximately 250,000 infants and young children are hospitalized each year in the United States for lower respiratory tract infection, and no etiologic agent is found in 12%–39% of cases.

The virus screening system that detected HBoV employs host DNA depletion, random polymerase chain reaction amplification, large-scale sequencing, and bioinformatics.

A newly identified parvovirus appears to cause lower respiratory tract infections in children, a team of scientists in Sweden and Singapore reported.

They detected the virus—provisionally named human bocavirus (HBoV)—through a rapid new system for large-scale molecular virus screening of clinical samples without the need for cultures and with minimal hands-on effort. Their method should make it feasible to systematically explore all viruses that affect humans, including unidentified ones, reported Tobias Allander, M.D., of Karolinska University Hospital, Stockholm, and his associates (Proc. Natl. Acad. Sci. USA 2005;102:12891–6).

To assess HBoV's clinical effects, the investigators screened culture-negative nasopharyngeal aspirate samples from 266 pediatric patients and 112 adults seen in clinics. Seven samples from infants and children were positive for HBoV. A subsequent retrospective study of all 540 aspirates available from the pediatric infectious diseases ward at the hospital found HBoV in 17 patients (3%), and 14 of these had no other viruses present. HBoV is the likely cause of the respiratory distress and fever in these patients, the investigators concluded.

Seven of the 14 patients underwent chest x-ray, and results showed interstitial bilateral infiltrates in 6 patients.

Approximately 250,000 infants and young children are hospitalized each year in the United States for lower respiratory tract infection, and no etiologic agent is found in 12%–39% of cases.

The virus screening system that detected HBoV employs host DNA depletion, random polymerase chain reaction amplification, large-scale sequencing, and bioinformatics.

A newly identified parvovirus appears to cause lower respiratory tract infections in children, a team of scientists in Sweden and Singapore reported.

They detected the virus—provisionally named human bocavirus (HBoV)—through a rapid new system for large-scale molecular virus screening of clinical samples without the need for cultures and with minimal hands-on effort. Their method should make it feasible to systematically explore all viruses that affect humans, including unidentified ones, reported Tobias Allander, M.D., of Karolinska University Hospital, Stockholm, and his associates (Proc. Natl. Acad. Sci. USA 2005;102:12891–6).

To assess HBoV's clinical effects, the investigators screened culture-negative nasopharyngeal aspirate samples from 266 pediatric patients and 112 adults seen in clinics. Seven samples from infants and children were positive for HBoV. A subsequent retrospective study of all 540 aspirates available from the pediatric infectious diseases ward at the hospital found HBoV in 17 patients (3%), and 14 of these had no other viruses present. HBoV is the likely cause of the respiratory distress and fever in these patients, the investigators concluded.

Seven of the 14 patients underwent chest x-ray, and results showed interstitial bilateral infiltrates in 6 patients.

Approximately 250,000 infants and young children are hospitalized each year in the United States for lower respiratory tract infection, and no etiologic agent is found in 12%–39% of cases.

The virus screening system that detected HBoV employs host DNA depletion, random polymerase chain reaction amplification, large-scale sequencing, and bioinformatics.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17 α-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists recommended in 2003 that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm birth by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant, said Dr. Caritis, professor and chief of maternal-fetal medicine at the University of Pittsburgh. Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies, and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered. “I think this is still the best study we have” on preventing preterm birth with progesterone, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial. Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said.

There is no evidence that oral progesterone affects preterm birth risk, he added.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17 α-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists recommended in 2003 that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm birth by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant, said Dr. Caritis, professor and chief of maternal-fetal medicine at the University of Pittsburgh. Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies, and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered. “I think this is still the best study we have” on preventing preterm birth with progesterone, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial. Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said.

There is no evidence that oral progesterone affects preterm birth risk, he added.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17 α-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists recommended in 2003 that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm birth by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant, said Dr. Caritis, professor and chief of maternal-fetal medicine at the University of Pittsburgh. Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies, and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered. “I think this is still the best study we have” on preventing preterm birth with progesterone, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial. Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said.

There is no evidence that oral progesterone affects preterm birth risk, he added.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point, no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (consistent with osteoporosis) has a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” Steven R. Cummings, M.D., said in a separate presentation.

He noted the WHO's fracture risk index is based on data from 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, Dr. Cummings said.

Adding bone density measurement to other factors in the index significantly strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point, no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (consistent with osteoporosis) has a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” Steven R. Cummings, M.D., said in a separate presentation.

He noted the WHO's fracture risk index is based on data from 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, Dr. Cummings said.

Adding bone density measurement to other factors in the index significantly strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — A yet to be released tool developed by the World Health Organization should help physicians calculate an individual's absolute risk for bone fracture and provide a basis for counseling patients regarding treatment, experts said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The expected WHO model will estimate an individual's risk of developing a fragility fracture over the next decade, based on factors that may include age, bone mineral density of the femoral neck, a history of previous fracture, family history of fracture, smoking and alcohol use, steroid use, and the presence of rheumatoid arthritis.

At this point, no one knows exactly which factors will be included in the model, said Steven T. Harris, M.D., clinical professor of medicine at the University of California, San Francisco.

Calculating absolute risk for fracture greatly assists therapeutic decision-making, he said.

For example, a 2001 model looked at the 10-year probability of fractures in the hip, forearm, humerus, or spine based simply on age and bone density. A 45-year-old with a T score of -3 (consistent with osteoporosis) has a 10% risk of fracture over the next 10 years, but the fracture risk increases to 30% in a 75-year-old with the same bone density.

The WHO model “is going to be far better than telling someone they have osteoporosis, giving them a prescription, and saying goodbye,” Dr. Harris said. “Getting people engaged in conversation about what their risk is, and what can be done with contemporary treatment, is going to make therapy a lot more rational.”

If a clinician could tell a 55-year-old patient who is osteopenic (with a T score of -2) that the patient's absolute risk for fracture is 10% over the next 10 years, and that contemporary treatments could reduce that risk to 5%, that should help the patient decide whether the potential improvement is worth the cost or inconvenience associated with therapy.

Calculations of absolute risk also are likely to be used by insurers in the near future to decide whether to cover medical therapy for improving bone density. It may be that therapy for someone with a 20% risk of fracture will be covered, but patients with a 10% risk will have to pay for the medications themselves.

The new WHO index is due to be released “imminently,” Steven R. Cummings, M.D., said in a separate presentation.

He noted the WHO's fracture risk index is based on data from 60,000 women in 12 cohorts of patients, mostly Europeans, and needs to be validated in other populations, including that of the United States.

He lauded the project's objective of establishing a set of universal factors that could be used to identify absolute fracture risk. “I think this is a very noble goal that will probably have important clinical value,” said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Some studies have been using the index to compare the value of bone density measurements with the value of other risk factors in predicting fractures. Using the index alone without measuring bone density seems to be pretty good at predicting hip fractures, and is modestly valuable in predicting other osteoporotic fractures.

Having “an index of risk factors may be useful, particularly in places where you don't have bone density testing, or if you're deciding whether or not” to measure a patient's bone density, Dr. Cummings said.

Adding bone density measurement to other factors in the index significantly strengthens the ability to predict hip fracture and mildly strengthens the ability to predict other fractures, but the opposite does not seem to be true.

“It's not clear that adding risk factors, once you know the bone density, will substantially improve the clinical judgments you can make about treatment with medication,” Dr. Cummings said.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood, the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy.

The study involved postmenopausal women, aged 55 to 80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, Dr. Cummings said.

Among women who participated in the study and who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment.

A slightly greater reduction in fracture risk was seen in those women who lost as much as 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits of the therapy occurred in women who lost more than 4% of bone density during the first year. In members of this subgroup, taking alendronate reduced the risk of fracture by about 80%–90%, compared with placebo.

“Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who also works as a consultant and speaker for two companies that manufacture bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, Dr. Cummings advised.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood, the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy.

The study involved postmenopausal women, aged 55 to 80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, Dr. Cummings said.

Among women who participated in the study and who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment.

A slightly greater reduction in fracture risk was seen in those women who lost as much as 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits of the therapy occurred in women who lost more than 4% of bone density during the first year. In members of this subgroup, taking alendronate reduced the risk of fracture by about 80%–90%, compared with placebo.

“Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who also works as a consultant and speaker for two companies that manufacture bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, Dr. Cummings advised.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood, the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy.

The study involved postmenopausal women, aged 55 to 80 years, who were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, Dr. Cummings said.

Among women who participated in the study and who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment.

A slightly greater reduction in fracture risk was seen in those women who lost as much as 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits of the therapy occurred in women who lost more than 4% of bone density during the first year. In members of this subgroup, taking alendronate reduced the risk of fracture by about 80%–90%, compared with placebo.

“Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who also works as a consultant and speaker for two companies that manufacture bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, Dr. Cummings advised.

STANFORD, CALIF. — In the ideologic tug-of-war among nutritionists about how best to help obese children, the 2005 federal dietary guidelines pull for controlling children's consumption of calories.

“We emphasize that modest reductions in energy intake are appropriate” to reduce the body mass index and the rate of weight gain while allowing continued growth and development, Janet C. King, Ph.D., said at a conference on perinatal and pediatric nutrition. Dr. King chaired the scientific advisory committee for the 2005 Dietary Guidelines for Americans, produced by the U.S. Department of Health and Human Services and the Department of Agriculture.

Another speaker at the conference, nationally known children's nutritionist Ellyn Satter, argued that restricting food from children backfires by disrupting their own internal regulators for healthy feeding. She called for better attention to feeding dynamics and education of parents.

The recommendation regarding overweight children is 1 of 18 recommendations for special subgroups of the population presented in the document. Others that address physical activity recommend that children and adolescents engage in at least 60 minutes of physical activity per day on a minimum of 5 days each week. “Very, very, very few children are reaching this standard,” said Dr. King, professor emeritus of nutrition at the University of California, Berkeley, and UC Davis.

Children and adolescents earned a special recommendation under the heading, “Choose fats wisely for good health.” The advisory committee felt that the recommendation that adults obtain 20%–35% of energy from fat in the diet was inappropriate for younger people. For children aged 2–3 years, fat should comprise 30%–35% of energy intake. For those aged 4–18 years, total fat should comprise 25%–35% of the diet, she said. Most fats should come from polyunsaturated and monounsaturated fatty acids, contained in foods such as fish, nuts, and vegetable oils.

Below the lower end of the desired fat content ranges, it's difficult to meet the recommended intakes of helpful fatty acids and vitamin E in each age group, Dr. King noted at the conference, jointly sponsored by Symposia Medicus and Stanford University. When diets contain more than 35% fat, the intake of saturated fat increases to levels that create a risk for chronic disease, evidence suggests.

Children and adolescents also need to “choose carbohydrates wisely” to make sure they get high-fiber foods that contribute 14 g of fiber per 1,000 calories and avoid excessive calories from added sugar, she said. “Children can become constipated just like adults due to a lack of fiber in their diets.”

A children's version of the signature graphic representation of the guidelines—MyPyramid.gov—soon will be released. Dr. King said the government has no plans to create a version of MyPyramid.gov for another deserving subpopulation: pregnant and lactating women. “I was very disappointed to hear that,” she said.

Women and teens of childbearing age who might become pregnant should eat iron-rich foods or iron-fortified foods and consume these with an enhancer of iron absorption, such as foods rich in vitamin C, according to one special recommendation. In addition, these women and pregnant women in the first trimester should consume at least 400 mcg/day of synthetic folic acid.

As for controlling calories, pregnant women need to eat enough for appropriate weight gain, but moderate weight reduction in breast-feeding women is safe and does not compromise the weight gain of the infant.

Regular or acute exercise will not harm a breast-feeding mother's ability to breast-feed successfully, according to the guidelines. Pregnant women should engage in at least 30 minutes of moderate-intensity physical activity on 5 or more days each week unless there's a medical or obstetric complication that would limit the safety of activity.

STANFORD, CALIF. — In the ideologic tug-of-war among nutritionists about how best to help obese children, the 2005 federal dietary guidelines pull for controlling children's consumption of calories.

“We emphasize that modest reductions in energy intake are appropriate” to reduce the body mass index and the rate of weight gain while allowing continued growth and development, Janet C. King, Ph.D., said at a conference on perinatal and pediatric nutrition. Dr. King chaired the scientific advisory committee for the 2005 Dietary Guidelines for Americans, produced by the U.S. Department of Health and Human Services and the Department of Agriculture.

Another speaker at the conference, nationally known children's nutritionist Ellyn Satter, argued that restricting food from children backfires by disrupting their own internal regulators for healthy feeding. She called for better attention to feeding dynamics and education of parents.

The recommendation regarding overweight children is 1 of 18 recommendations for special subgroups of the population presented in the document. Others that address physical activity recommend that children and adolescents engage in at least 60 minutes of physical activity per day on a minimum of 5 days each week. “Very, very, very few children are reaching this standard,” said Dr. King, professor emeritus of nutrition at the University of California, Berkeley, and UC Davis.

Children and adolescents earned a special recommendation under the heading, “Choose fats wisely for good health.” The advisory committee felt that the recommendation that adults obtain 20%–35% of energy from fat in the diet was inappropriate for younger people. For children aged 2–3 years, fat should comprise 30%–35% of energy intake. For those aged 4–18 years, total fat should comprise 25%–35% of the diet, she said. Most fats should come from polyunsaturated and monounsaturated fatty acids, contained in foods such as fish, nuts, and vegetable oils.

Below the lower end of the desired fat content ranges, it's difficult to meet the recommended intakes of helpful fatty acids and vitamin E in each age group, Dr. King noted at the conference, jointly sponsored by Symposia Medicus and Stanford University. When diets contain more than 35% fat, the intake of saturated fat increases to levels that create a risk for chronic disease, evidence suggests.

Children and adolescents also need to “choose carbohydrates wisely” to make sure they get high-fiber foods that contribute 14 g of fiber per 1,000 calories and avoid excessive calories from added sugar, she said. “Children can become constipated just like adults due to a lack of fiber in their diets.”

A children's version of the signature graphic representation of the guidelines—MyPyramid.gov—soon will be released. Dr. King said the government has no plans to create a version of MyPyramid.gov for another deserving subpopulation: pregnant and lactating women. “I was very disappointed to hear that,” she said.

Women and teens of childbearing age who might become pregnant should eat iron-rich foods or iron-fortified foods and consume these with an enhancer of iron absorption, such as foods rich in vitamin C, according to one special recommendation. In addition, these women and pregnant women in the first trimester should consume at least 400 mcg/day of synthetic folic acid.

As for controlling calories, pregnant women need to eat enough for appropriate weight gain, but moderate weight reduction in breast-feeding women is safe and does not compromise the weight gain of the infant.

Regular or acute exercise will not harm a breast-feeding mother's ability to breast-feed successfully, according to the guidelines. Pregnant women should engage in at least 30 minutes of moderate-intensity physical activity on 5 or more days each week unless there's a medical or obstetric complication that would limit the safety of activity.

STANFORD, CALIF. — In the ideologic tug-of-war among nutritionists about how best to help obese children, the 2005 federal dietary guidelines pull for controlling children's consumption of calories.

“We emphasize that modest reductions in energy intake are appropriate” to reduce the body mass index and the rate of weight gain while allowing continued growth and development, Janet C. King, Ph.D., said at a conference on perinatal and pediatric nutrition. Dr. King chaired the scientific advisory committee for the 2005 Dietary Guidelines for Americans, produced by the U.S. Department of Health and Human Services and the Department of Agriculture.

Another speaker at the conference, nationally known children's nutritionist Ellyn Satter, argued that restricting food from children backfires by disrupting their own internal regulators for healthy feeding. She called for better attention to feeding dynamics and education of parents.

The recommendation regarding overweight children is 1 of 18 recommendations for special subgroups of the population presented in the document. Others that address physical activity recommend that children and adolescents engage in at least 60 minutes of physical activity per day on a minimum of 5 days each week. “Very, very, very few children are reaching this standard,” said Dr. King, professor emeritus of nutrition at the University of California, Berkeley, and UC Davis.

Children and adolescents earned a special recommendation under the heading, “Choose fats wisely for good health.” The advisory committee felt that the recommendation that adults obtain 20%–35% of energy from fat in the diet was inappropriate for younger people. For children aged 2–3 years, fat should comprise 30%–35% of energy intake. For those aged 4–18 years, total fat should comprise 25%–35% of the diet, she said. Most fats should come from polyunsaturated and monounsaturated fatty acids, contained in foods such as fish, nuts, and vegetable oils.

Below the lower end of the desired fat content ranges, it's difficult to meet the recommended intakes of helpful fatty acids and vitamin E in each age group, Dr. King noted at the conference, jointly sponsored by Symposia Medicus and Stanford University. When diets contain more than 35% fat, the intake of saturated fat increases to levels that create a risk for chronic disease, evidence suggests.

Children and adolescents also need to “choose carbohydrates wisely” to make sure they get high-fiber foods that contribute 14 g of fiber per 1,000 calories and avoid excessive calories from added sugar, she said. “Children can become constipated just like adults due to a lack of fiber in their diets.”

A children's version of the signature graphic representation of the guidelines—MyPyramid.gov—soon will be released. Dr. King said the government has no plans to create a version of MyPyramid.gov for another deserving subpopulation: pregnant and lactating women. “I was very disappointed to hear that,” she said.

Women and teens of childbearing age who might become pregnant should eat iron-rich foods or iron-fortified foods and consume these with an enhancer of iron absorption, such as foods rich in vitamin C, according to one special recommendation. In addition, these women and pregnant women in the first trimester should consume at least 400 mcg/day of synthetic folic acid.

As for controlling calories, pregnant women need to eat enough for appropriate weight gain, but moderate weight reduction in breast-feeding women is safe and does not compromise the weight gain of the infant.

Regular or acute exercise will not harm a breast-feeding mother's ability to breast-feed successfully, according to the guidelines. Pregnant women should engage in at least 30 minutes of moderate-intensity physical activity on 5 or more days each week unless there's a medical or obstetric complication that would limit the safety of activity.

STANFORD, CALIF. — The 2005 federal dietary guidelines could do more harm than good if parents try to push their children to eat specific amounts of foods recommended in the guidelines, Ellyn Satter said at a conference on perinatal and pediatric nutrition.

Overly controlling the way children eat undermines their innate self-regulation in feeding, which often leads to obesity, said Ms. Satter, author of several books, including “Your Child's Weight: Helping Without Harming” (Madison, Wis.: Kelcy Press, 2005). Organizers of the conference credited the larger-than-usual turnout in part to Ms. Satter's presence on the program.

The 2005 edition of Dietary Guidelines for Americans emphasizes nutrition but is not grounded in feeding dynamics, said Ms. Satter of Madison, Wis.

By listing recommended amounts of food groups (cups, ounces, or teaspoons of fruits, vegetables, whole grains, milk, oil) that are needed to meet daily nutrient requirements, the guidelines cross the “division of responsibility” that should allow the child to decide how much to eat, she said in an interview. (See box.)

Although well intentioned, the guidelines could help undermine children's internal regulators and contribute to obesity. “You're creating the very thing you're trying to prevent,” she said at the conference, which was jointly sponsored by Symposia Medicus and Stanford University.

Janet C. King, Ph.D., chair of the scientific advisory committee behind the dietary guidelines, said that the federal recommendations and Ms. Satter's approach are not that far apart. Parents need to know the desired amounts of food groups in order to put a healthy variety of foods on the table. That information is provided by the dietary guidelines. Then it's up to behavioral specialists like Ms. Satter to offer advice on implementing the guidelines, Dr. King said in an interview (see story below).

“You have to know what your [nutritional] goals are, and then you need the systems of behaviorists to help people make these changes. We would agree strongly with that,” said Dr. King, a senior scientist at Children's Hospital Oakland (Calif.) Research Institute.

“If you follow the food patterns and recommended servings, you'll meet your nutritional requirements,” she said.

Ms. Satter said that one of the biggest problems she sees in family eating dynamics is the overrestriction of children's access to foods.

The federal dietary guidelines have a positive focus rather than a focus on what not to eat, Dr. King pointed out. Parents should “focus on what are good foods, focus on the nutrient-rich foods, and then also keep in mind that you need to balance intake with output,” she said. “We felt that it was important to develop a foundation for good food habits early in life.”

Children already have that foundation, if parents will only let go of the need to control it and pay proper attention to their own responsibilities in feeding, Ms. Satter said.

Doing a good job with feeding and parenting means having regular and reliable sit-down family meals and sit-down snack breaks that include a variety of tasty, wholesome foods. Parents should regularly include “forbidden” foods at meals and as snacks so that children won't be compelled to sneak around and overeat them at other times. This implies trusting children to decide whether and how much to eat.

Clinicians should ask parents questions about past and present feeding habits, as well as teach about developmental stage-appropriate feeding and encourage the division of responsibility for feeding. Emphasizing growth tracking—not arbitrary growth cutoffs—can help parents accept consistent growth as normal, even if the child's weight and height fall outside average limits.

“Accept the child you have, not the one you thought you should have,” she said.

Ms. Satter applies her division of responsibilities to physical activity as well as to feeding. Parents control the structure of, safety of, and opportunities for activity. Children decide whether to move, the manner of moving, and how much to move. There is one item that she believes in restricting, however: television.

“Child overweight isn't just about eating too much and exercising too little. It is about our failure as a culture on all levels to do good parenting,” she said.

Parent, Child Make Healthy Eating Team

When parents appropriately divide the responsibilities of feeding between parents and children, healthy eating habits flourish, Ms. Satter said.

Here's how she divides the duties:

▸ Parent: What, when, and where. The parent chooses and prepares a variety of foods that will allow predictable growth in the child. Structure is key: providing regular, reliable meals and sit-down snacks, and not letting the child graze for food or beverages between times. The parent should make eating time pleasant, communicate age-appropriate expectations of mastery of eating, and accept the child's size and shape.

▸ Child: How much and whether. The child decides whether to eat, and what to eat from the selections available. Parents must trust children to do their jobs regarding eating. Children will eat. They will know how much to eat. They will eat a variety of foods. They will grow predictably, and gradually will learn to manage the “what, when, and where” decisions for themselves. Only after they leave home do they become fully independent eaters.

This does not mean that a parent must provide junk food if a child wants it. “The parent is in charge of the menu and the child can eat or not eat. It's not an open menu,” Ms. Satter explained. But the parent should put food on the table that's nutritionally and developmentally appropriate for the child. A parent who decides to eat a low-fat diet should still offer food with a variety of fat content at meals so that children can choose what's appropriate for them.

Early feeding errors by parents who try to control the child's “how much” and “whether” decisions undermine the child's internal regulators and lead to too-rapid weight gain or loss. Physicians can help parents who are expecting or who have children by teaching this division of responsibility and emphasizing the skills of providing food, not depriving them of foods, Ms. Satter said.

When families with overweight children adopt this model, a child may overeat initially and parents may panic, she added. If they hang in and trust, however, then the child's internal regulators should take over within a few weeks and provide healthy eating habits for life.

STANFORD, CALIF. — The 2005 federal dietary guidelines could do more harm than good if parents try to push their children to eat specific amounts of foods recommended in the guidelines, Ellyn Satter said at a conference on perinatal and pediatric nutrition.

Overly controlling the way children eat undermines their innate self-regulation in feeding, which often leads to obesity, said Ms. Satter, author of several books, including “Your Child's Weight: Helping Without Harming” (Madison, Wis.: Kelcy Press, 2005). Organizers of the conference credited the larger-than-usual turnout in part to Ms. Satter's presence on the program.

The 2005 edition of Dietary Guidelines for Americans emphasizes nutrition but is not grounded in feeding dynamics, said Ms. Satter of Madison, Wis.

By listing recommended amounts of food groups (cups, ounces, or teaspoons of fruits, vegetables, whole grains, milk, oil) that are needed to meet daily nutrient requirements, the guidelines cross the “division of responsibility” that should allow the child to decide how much to eat, she said in an interview. (See box.)

Although well intentioned, the guidelines could help undermine children's internal regulators and contribute to obesity. “You're creating the very thing you're trying to prevent,” she said at the conference, which was jointly sponsored by Symposia Medicus and Stanford University.

Janet C. King, Ph.D., chair of the scientific advisory committee behind the dietary guidelines, said that the federal recommendations and Ms. Satter's approach are not that far apart. Parents need to know the desired amounts of food groups in order to put a healthy variety of foods on the table. That information is provided by the dietary guidelines. Then it's up to behavioral specialists like Ms. Satter to offer advice on implementing the guidelines, Dr. King said in an interview (see story below).

“You have to know what your [nutritional] goals are, and then you need the systems of behaviorists to help people make these changes. We would agree strongly with that,” said Dr. King, a senior scientist at Children's Hospital Oakland (Calif.) Research Institute.

“If you follow the food patterns and recommended servings, you'll meet your nutritional requirements,” she said.

Ms. Satter said that one of the biggest problems she sees in family eating dynamics is the overrestriction of children's access to foods.

The federal dietary guidelines have a positive focus rather than a focus on what not to eat, Dr. King pointed out. Parents should “focus on what are good foods, focus on the nutrient-rich foods, and then also keep in mind that you need to balance intake with output,” she said. “We felt that it was important to develop a foundation for good food habits early in life.”

Children already have that foundation, if parents will only let go of the need to control it and pay proper attention to their own responsibilities in feeding, Ms. Satter said.

Doing a good job with feeding and parenting means having regular and reliable sit-down family meals and sit-down snack breaks that include a variety of tasty, wholesome foods. Parents should regularly include “forbidden” foods at meals and as snacks so that children won't be compelled to sneak around and overeat them at other times. This implies trusting children to decide whether and how much to eat.

Clinicians should ask parents questions about past and present feeding habits, as well as teach about developmental stage-appropriate feeding and encourage the division of responsibility for feeding. Emphasizing growth tracking—not arbitrary growth cutoffs—can help parents accept consistent growth as normal, even if the child's weight and height fall outside average limits.

“Accept the child you have, not the one you thought you should have,” she said.

Ms. Satter applies her division of responsibilities to physical activity as well as to feeding. Parents control the structure of, safety of, and opportunities for activity. Children decide whether to move, the manner of moving, and how much to move. There is one item that she believes in restricting, however: television.

“Child overweight isn't just about eating too much and exercising too little. It is about our failure as a culture on all levels to do good parenting,” she said.

Parent, Child Make Healthy Eating Team

When parents appropriately divide the responsibilities of feeding between parents and children, healthy eating habits flourish, Ms. Satter said.

Here's how she divides the duties:

▸ Parent: What, when, and where. The parent chooses and prepares a variety of foods that will allow predictable growth in the child. Structure is key: providing regular, reliable meals and sit-down snacks, and not letting the child graze for food or beverages between times. The parent should make eating time pleasant, communicate age-appropriate expectations of mastery of eating, and accept the child's size and shape.

▸ Child: How much and whether. The child decides whether to eat, and what to eat from the selections available. Parents must trust children to do their jobs regarding eating. Children will eat. They will know how much to eat. They will eat a variety of foods. They will grow predictably, and gradually will learn to manage the “what, when, and where” decisions for themselves. Only after they leave home do they become fully independent eaters.

This does not mean that a parent must provide junk food if a child wants it. “The parent is in charge of the menu and the child can eat or not eat. It's not an open menu,” Ms. Satter explained. But the parent should put food on the table that's nutritionally and developmentally appropriate for the child. A parent who decides to eat a low-fat diet should still offer food with a variety of fat content at meals so that children can choose what's appropriate for them.

Early feeding errors by parents who try to control the child's “how much” and “whether” decisions undermine the child's internal regulators and lead to too-rapid weight gain or loss. Physicians can help parents who are expecting or who have children by teaching this division of responsibility and emphasizing the skills of providing food, not depriving them of foods, Ms. Satter said.

When families with overweight children adopt this model, a child may overeat initially and parents may panic, she added. If they hang in and trust, however, then the child's internal regulators should take over within a few weeks and provide healthy eating habits for life.

STANFORD, CALIF. — The 2005 federal dietary guidelines could do more harm than good if parents try to push their children to eat specific amounts of foods recommended in the guidelines, Ellyn Satter said at a conference on perinatal and pediatric nutrition.

Overly controlling the way children eat undermines their innate self-regulation in feeding, which often leads to obesity, said Ms. Satter, author of several books, including “Your Child's Weight: Helping Without Harming” (Madison, Wis.: Kelcy Press, 2005). Organizers of the conference credited the larger-than-usual turnout in part to Ms. Satter's presence on the program.

The 2005 edition of Dietary Guidelines for Americans emphasizes nutrition but is not grounded in feeding dynamics, said Ms. Satter of Madison, Wis.

By listing recommended amounts of food groups (cups, ounces, or teaspoons of fruits, vegetables, whole grains, milk, oil) that are needed to meet daily nutrient requirements, the guidelines cross the “division of responsibility” that should allow the child to decide how much to eat, she said in an interview. (See box.)

Although well intentioned, the guidelines could help undermine children's internal regulators and contribute to obesity. “You're creating the very thing you're trying to prevent,” she said at the conference, which was jointly sponsored by Symposia Medicus and Stanford University.

Janet C. King, Ph.D., chair of the scientific advisory committee behind the dietary guidelines, said that the federal recommendations and Ms. Satter's approach are not that far apart. Parents need to know the desired amounts of food groups in order to put a healthy variety of foods on the table. That information is provided by the dietary guidelines. Then it's up to behavioral specialists like Ms. Satter to offer advice on implementing the guidelines, Dr. King said in an interview (see story below).

“You have to know what your [nutritional] goals are, and then you need the systems of behaviorists to help people make these changes. We would agree strongly with that,” said Dr. King, a senior scientist at Children's Hospital Oakland (Calif.) Research Institute.

“If you follow the food patterns and recommended servings, you'll meet your nutritional requirements,” she said.

Ms. Satter said that one of the biggest problems she sees in family eating dynamics is the overrestriction of children's access to foods.

The federal dietary guidelines have a positive focus rather than a focus on what not to eat, Dr. King pointed out. Parents should “focus on what are good foods, focus on the nutrient-rich foods, and then also keep in mind that you need to balance intake with output,” she said. “We felt that it was important to develop a foundation for good food habits early in life.”

Children already have that foundation, if parents will only let go of the need to control it and pay proper attention to their own responsibilities in feeding, Ms. Satter said.

Doing a good job with feeding and parenting means having regular and reliable sit-down family meals and sit-down snack breaks that include a variety of tasty, wholesome foods. Parents should regularly include “forbidden” foods at meals and as snacks so that children won't be compelled to sneak around and overeat them at other times. This implies trusting children to decide whether and how much to eat.

Clinicians should ask parents questions about past and present feeding habits, as well as teach about developmental stage-appropriate feeding and encourage the division of responsibility for feeding. Emphasizing growth tracking—not arbitrary growth cutoffs—can help parents accept consistent growth as normal, even if the child's weight and height fall outside average limits.

“Accept the child you have, not the one you thought you should have,” she said.

Ms. Satter applies her division of responsibilities to physical activity as well as to feeding. Parents control the structure of, safety of, and opportunities for activity. Children decide whether to move, the manner of moving, and how much to move. There is one item that she believes in restricting, however: television.

“Child overweight isn't just about eating too much and exercising too little. It is about our failure as a culture on all levels to do good parenting,” she said.

Parent, Child Make Healthy Eating Team

When parents appropriately divide the responsibilities of feeding between parents and children, healthy eating habits flourish, Ms. Satter said.

Here's how she divides the duties:

▸ Parent: What, when, and where. The parent chooses and prepares a variety of foods that will allow predictable growth in the child. Structure is key: providing regular, reliable meals and sit-down snacks, and not letting the child graze for food or beverages between times. The parent should make eating time pleasant, communicate age-appropriate expectations of mastery of eating, and accept the child's size and shape.

▸ Child: How much and whether. The child decides whether to eat, and what to eat from the selections available. Parents must trust children to do their jobs regarding eating. Children will eat. They will know how much to eat. They will eat a variety of foods. They will grow predictably, and gradually will learn to manage the “what, when, and where” decisions for themselves. Only after they leave home do they become fully independent eaters.

This does not mean that a parent must provide junk food if a child wants it. “The parent is in charge of the menu and the child can eat or not eat. It's not an open menu,” Ms. Satter explained. But the parent should put food on the table that's nutritionally and developmentally appropriate for the child. A parent who decides to eat a low-fat diet should still offer food with a variety of fat content at meals so that children can choose what's appropriate for them.

Early feeding errors by parents who try to control the child's “how much” and “whether” decisions undermine the child's internal regulators and lead to too-rapid weight gain or loss. Physicians can help parents who are expecting or who have children by teaching this division of responsibility and emphasizing the skills of providing food, not depriving them of foods, Ms. Satter said.

When families with overweight children adopt this model, a child may overeat initially and parents may panic, she added. If they hang in and trust, however, then the child's internal regulators should take over within a few weeks and provide healthy eating habits for life.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—“many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white.

Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study, patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” she said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback said that she has no affiliation with companies that make vitamin D supplements.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—“many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white.

Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study, patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” she said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback said that she has no affiliation with companies that make vitamin D supplements.

SAN FRANCISCO — A majority of 1,536 elderly women taking medication to prevent or treat osteoporosis were deficient in vitamin D, a study of community-dwelling patients found.

The findings echo a previous study that found 56% of medical inpatients had vitamin D deficiency. “This is a very common problem” that deserves more attention, Dolores M. Shoback, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Physicians should look more carefully for vitamin D deficiency in inpatients and outpatients, even those who are ambulatory, on prescription therapy for osteoporosis, and lacking risk factors for vitamin D deficiency—“many of the patients, probably, in our own practices,” said Dr. Shoback, professor of medicine at the university.

The recent outpatient study included postmenopausal women at 61 locations in North America who had been taking bisphosphonates, calcitonin, or a selective estrogen receptor modulator for at least 3 months under a physician's care to prevent or treat osteoporosis. They averaged 71 years in age, and were 92% white.

Investigators administered a questionnaire to assess risk factors for vitamin D deficiency and measured the women's serum concentrations of parathyroid hormone (PTH) and 25-hydroxyvitamin D—known as 25(OH)D—the form of vitamin D stored in the body.

They found that 52% of the 1,536 women had levels of 25(OH)D lower than 30 ng/mL. Of these, 36% had levels below 25 ng/mL, and 18% were below 20 ng/mL, showing that most of the women with inadequate vitamin D were severely deficient (J. Clin. Endocrinol. Metab. 2005;90:3215–24).

“We aren't doing a good job with the people we're actively treating for osteoporosis,” said Dr. Shoback. Vitamin D deficiency is one of the most common causes of secondary osteoporosis.

Although there's no consensus on how much vitamin D the human body needs, the idea that 15–25 ng/mL is adequate has been replaced in the last few years by general cutoffs closer to 30 ng/mL or higher, she said. Some experts say people need at least 20 ng/mL 25(OH)D or else PTH levels rise and frank hyperparathyroidism develops. Others say that elderly people need 32–36 ng/mL to maximize intestinal calcium transport.

In the study, patients tended to develop secondary hyperparathyroidism at 25(OH)D levels of 25 ng/mL and lower. Many physicians use PTH levels to help diagnose vitamin D deficiency, but the study found that high PTH is not 100% sensitive for low vitamin D. Only 75% of women with 25(OH)D levels of 0–9 ng/mL had secondary hyperparathyroidism. “This surprised me,” Dr. Shoback said.

Women who had not discussed vitamin D and bone health with their doctors were more likely to have 25(OH)D levels below 30 ng/mL. “Sometimes we think we're talking to the wall or ourselves, but these discussions actually may be having some kind of an impact,” she said.

Other risk factors for vitamin D deficiency included age older than 80, a body mass index over 30 kg/m

The 1998 inpatient study that detected vitamin D deficiency in 56% of 290 patients consecutively admitted to a hospital medical service also found that risk factors predicted the deficiency only about 60% of the time. The investigators recommended that medical inpatients be screened for vitamin D deficiency, she noted. Taking multivitamins did not prevent vitamin D deficiency in that study.

Dr. Shoback said that she has no affiliation with companies that make vitamin D supplements.

SAN FRANCISCO — Plaques in the carotid arteries were associated with an increased risk of death due to cardiovascular disease in a prospective 10-year study of 2,651 people chosen randomly from the general population.

Previous data have shown a significant association between carotid artery plaque burden and risk of cardiovascular death in people with known cardiovascular disease. The current study shows that carotid artery plaque burden provides independent prognostic information in the general population as well, Marina Krintel Christensen, M.D., said in a poster presentation at the annual meeting of the American Society of Hypertension.

The investigators examined the carotid arteries of apparently healthy people aged 41, 51, 61, or 71 years in 1993 and 1994 by using B-mode ultrasound. Ten years later, the investigators followed up by recording the number and causes of death.

At baseline, they found carotid artery plaques in 724 subjects—423 men and 301 women, said Dr. Christensen and her associates at Glostrup (Denmark) University Hospital.

The presence of plaques was linked to a 57% increase in the risk of cardiovascular death over the 10-year period after adjustment for conventional risk factors for cardiovascular death including age, cholesterol levels, smoking status, fasting glucose levels, gender, mean arterial pressure, pulse pressure, and prior cardiovascular disease.

Gender and smoking status did not alter the relationship between carotid artery plaques and cardiovascular death.

The study suggests that carotid artery plaques are another risk factor that might be assessed in deciding whether and how aggressively to treat patients with high blood pressure, Dr. Christensen said in an interview during the poster session. Conventional risk factors such as age, cholesterol, and smoking status provide plenty of information to guide management in most patients, but carotid ultrasound might be worth the added expense to look for plaques in borderline patients if physicians are having difficulty deciding on antihypertensive therapy, she said.

After 10 years, 3% of people with no plaques at baseline had died of cardiovascular causes, compared with 7% of people with one or two plaques and 19% of people with more than two plaques.

In men, the cardiovascular mortality rate at 10 years was 4% in those with no plaques at baseline, 7% in those with up to two plaques, and 25% in those with more than two plaques. In women, cardiovascular death rates were 1% with no plaques, 6% with up to two plaques, and 11% with more than two plaques.

SAN FRANCISCO — Plaques in the carotid arteries were associated with an increased risk of death due to cardiovascular disease in a prospective 10-year study of 2,651 people chosen randomly from the general population.

Previous data have shown a significant association between carotid artery plaque burden and risk of cardiovascular death in people with known cardiovascular disease. The current study shows that carotid artery plaque burden provides independent prognostic information in the general population as well, Marina Krintel Christensen, M.D., said in a poster presentation at the annual meeting of the American Society of Hypertension.

The investigators examined the carotid arteries of apparently healthy people aged 41, 51, 61, or 71 years in 1993 and 1994 by using B-mode ultrasound. Ten years later, the investigators followed up by recording the number and causes of death.

At baseline, they found carotid artery plaques in 724 subjects—423 men and 301 women, said Dr. Christensen and her associates at Glostrup (Denmark) University Hospital.

The presence of plaques was linked to a 57% increase in the risk of cardiovascular death over the 10-year period after adjustment for conventional risk factors for cardiovascular death including age, cholesterol levels, smoking status, fasting glucose levels, gender, mean arterial pressure, pulse pressure, and prior cardiovascular disease.

Gender and smoking status did not alter the relationship between carotid artery plaques and cardiovascular death.

The study suggests that carotid artery plaques are another risk factor that might be assessed in deciding whether and how aggressively to treat patients with high blood pressure, Dr. Christensen said in an interview during the poster session. Conventional risk factors such as age, cholesterol, and smoking status provide plenty of information to guide management in most patients, but carotid ultrasound might be worth the added expense to look for plaques in borderline patients if physicians are having difficulty deciding on antihypertensive therapy, she said.

After 10 years, 3% of people with no plaques at baseline had died of cardiovascular causes, compared with 7% of people with one or two plaques and 19% of people with more than two plaques.

In men, the cardiovascular mortality rate at 10 years was 4% in those with no plaques at baseline, 7% in those with up to two plaques, and 25% in those with more than two plaques. In women, cardiovascular death rates were 1% with no plaques, 6% with up to two plaques, and 11% with more than two plaques.

SAN FRANCISCO — Plaques in the carotid arteries were associated with an increased risk of death due to cardiovascular disease in a prospective 10-year study of 2,651 people chosen randomly from the general population.

Previous data have shown a significant association between carotid artery plaque burden and risk of cardiovascular death in people with known cardiovascular disease. The current study shows that carotid artery plaque burden provides independent prognostic information in the general population as well, Marina Krintel Christensen, M.D., said in a poster presentation at the annual meeting of the American Society of Hypertension.

The investigators examined the carotid arteries of apparently healthy people aged 41, 51, 61, or 71 years in 1993 and 1994 by using B-mode ultrasound. Ten years later, the investigators followed up by recording the number and causes of death.

At baseline, they found carotid artery plaques in 724 subjects—423 men and 301 women, said Dr. Christensen and her associates at Glostrup (Denmark) University Hospital.

The presence of plaques was linked to a 57% increase in the risk of cardiovascular death over the 10-year period after adjustment for conventional risk factors for cardiovascular death including age, cholesterol levels, smoking status, fasting glucose levels, gender, mean arterial pressure, pulse pressure, and prior cardiovascular disease.

Gender and smoking status did not alter the relationship between carotid artery plaques and cardiovascular death.

The study suggests that carotid artery plaques are another risk factor that might be assessed in deciding whether and how aggressively to treat patients with high blood pressure, Dr. Christensen said in an interview during the poster session. Conventional risk factors such as age, cholesterol, and smoking status provide plenty of information to guide management in most patients, but carotid ultrasound might be worth the added expense to look for plaques in borderline patients if physicians are having difficulty deciding on antihypertensive therapy, she said.

After 10 years, 3% of people with no plaques at baseline had died of cardiovascular causes, compared with 7% of people with one or two plaques and 19% of people with more than two plaques.

In men, the cardiovascular mortality rate at 10 years was 4% in those with no plaques at baseline, 7% in those with up to two plaques, and 25% in those with more than two plaques. In women, cardiovascular death rates were 1% with no plaques, 6% with up to two plaques, and 11% with more than two plaques.

VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.

Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.

Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC. Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.

Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).

A higher proportion of ob.gyns. (67%) knew HPV infections may clear without intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).

Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).

A second analysis of results related to HPV testing practices found that a minority uses HPV tests—35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians, Nidhi Jain, M.D., of the CDC in Atlanta said at the conference, sponsored by the University of California, San Francisco.

By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.

Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASCUS), and 98% of the 2,980 respondents use it for that purpose.

The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.

The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.

A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.

Ob.gyns. and nurse-midwives were most likely to do an HPV test following an ASCUS Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported in a third poster on the survey.

Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. About 48% said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the test as it relates to the Pap smear.

VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.

Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.

Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC. Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.

Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).

A higher proportion of ob.gyns. (67%) knew HPV infections may clear without intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).

Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).

A second analysis of results related to HPV testing practices found that a minority uses HPV tests—35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians, Nidhi Jain, M.D., of the CDC in Atlanta said at the conference, sponsored by the University of California, San Francisco.

By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.

Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASCUS), and 98% of the 2,980 respondents use it for that purpose.

The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.

The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.

A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.

Ob.gyns. and nurse-midwives were most likely to do an HPV test following an ASCUS Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported in a third poster on the survey.

Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. About 48% said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the test as it relates to the Pap smear.

VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.

Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.

Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC. Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.

Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).

A higher proportion of ob.gyns. (67%) knew HPV infections may clear without intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).

Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).

A second analysis of results related to HPV testing practices found that a minority uses HPV tests—35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians, Nidhi Jain, M.D., of the CDC in Atlanta said at the conference, sponsored by the University of California, San Francisco.

By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.

Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASCUS), and 98% of the 2,980 respondents use it for that purpose.

The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.

The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.

A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.

Ob.gyns. and nurse-midwives were most likely to do an HPV test following an ASCUS Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported in a third poster on the survey.

Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. About 48% said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the test as it relates to the Pap smear.

VANCOUVER, B.C. — Women over age 50 with normal Pap results who don't have human papillomavirus probably can safely be excused from cervical screening, Marc F.D. Baay, Ph.D., said in a poster presentation at the 22nd International Papillomavirus Conference.

That would encompass 93% of women older than 50 years, said Dr. Baay of the University of Antwerp, Belgium.

Dr. Baay and his associates followed 513 women in three age groups for a median of 3 years with 1,952 Pap smears and testing for high-risk human papillomavirus (HPV) types. Results showed 41 transient infections and 9 persistent HPV infections, with only 2 of the persistent infections in women aged 50 and up, they reported at the conference, sponsored by the University of California, San Francisco.

HPV infection in 16% of 68 women aged younger than 30 years was transient in every case. HPV infection in 14% of 175 women aged 30–49 years and 6% of 270 women aged 50 years and older was persistent in 4% of women in the middle-age group and less than 1% of the women over age 50. Five out of the nine persistent infections were related to HPV 16. All women had normal cytology results at the time HPV was first detected.

Six of the nine women with persistent infections developed abnormal cytology during the follow-up study. Only one of these women was over age 50; she developed high-grade squamous intraepithelial lesions (HSIL) at age 52. A biopsy showed cervical intraepithelial neoplasia grade 0 (CIN0).

The other five abnormal Pap results in women with persistent HPV came from women aged 30–49 years. A biopsy in one woman with HSIL found CIN3. Among three cases of low-grade squamous intraepithelial lesions (LSIL), one regressed spontaneously, and a biopsy in another found cervical intraepithelial neoplasia grade 3 (CIN3). One woman with persistent HPV in this middle-age group developed atypical squamous cells of undetermined significance (ASCUS).

Low-grade abnormal cytology also was seen in 10 HPV-negative women (7 with ASCUS and 3 with LSIL), but these lesions all regressed spontaneously.

The study suggests that canceling cervical screening for HPV-negative older women with normal Pap results would carry only a limited risk of missing cervical abnormalities or the development of slow-growing cervical cancer, Dr. Baay said.

VANCOUVER, B.C. — Women over age 50 with normal Pap results who don't have human papillomavirus probably can safely be excused from cervical screening, Marc F.D. Baay, Ph.D., said in a poster presentation at the 22nd International Papillomavirus Conference.

That would encompass 93% of women older than 50 years, said Dr. Baay of the University of Antwerp, Belgium.

Dr. Baay and his associates followed 513 women in three age groups for a median of 3 years with 1,952 Pap smears and testing for high-risk human papillomavirus (HPV) types. Results showed 41 transient infections and 9 persistent HPV infections, with only 2 of the persistent infections in women aged 50 and up, they reported at the conference, sponsored by the University of California, San Francisco.

HPV infection in 16% of 68 women aged younger than 30 years was transient in every case. HPV infection in 14% of 175 women aged 30–49 years and 6% of 270 women aged 50 years and older was persistent in 4% of women in the middle-age group and less than 1% of the women over age 50. Five out of the nine persistent infections were related to HPV 16. All women had normal cytology results at the time HPV was first detected.

Six of the nine women with persistent infections developed abnormal cytology during the follow-up study. Only one of these women was over age 50; she developed high-grade squamous intraepithelial lesions (HSIL) at age 52. A biopsy showed cervical intraepithelial neoplasia grade 0 (CIN0).

The other five abnormal Pap results in women with persistent HPV came from women aged 30–49 years. A biopsy in one woman with HSIL found CIN3. Among three cases of low-grade squamous intraepithelial lesions (LSIL), one regressed spontaneously, and a biopsy in another found cervical intraepithelial neoplasia grade 3 (CIN3). One woman with persistent HPV in this middle-age group developed atypical squamous cells of undetermined significance (ASCUS).

Low-grade abnormal cytology also was seen in 10 HPV-negative women (7 with ASCUS and 3 with LSIL), but these lesions all regressed spontaneously.

The study suggests that canceling cervical screening for HPV-negative older women with normal Pap results would carry only a limited risk of missing cervical abnormalities or the development of slow-growing cervical cancer, Dr. Baay said.

VANCOUVER, B.C. — Women over age 50 with normal Pap results who don't have human papillomavirus probably can safely be excused from cervical screening, Marc F.D. Baay, Ph.D., said in a poster presentation at the 22nd International Papillomavirus Conference.

That would encompass 93% of women older than 50 years, said Dr. Baay of the University of Antwerp, Belgium.

Dr. Baay and his associates followed 513 women in three age groups for a median of 3 years with 1,952 Pap smears and testing for high-risk human papillomavirus (HPV) types. Results showed 41 transient infections and 9 persistent HPV infections, with only 2 of the persistent infections in women aged 50 and up, they reported at the conference, sponsored by the University of California, San Francisco.

HPV infection in 16% of 68 women aged younger than 30 years was transient in every case. HPV infection in 14% of 175 women aged 30–49 years and 6% of 270 women aged 50 years and older was persistent in 4% of women in the middle-age group and less than 1% of the women over age 50. Five out of the nine persistent infections were related to HPV 16. All women had normal cytology results at the time HPV was first detected.

Six of the nine women with persistent infections developed abnormal cytology during the follow-up study. Only one of these women was over age 50; she developed high-grade squamous intraepithelial lesions (HSIL) at age 52. A biopsy showed cervical intraepithelial neoplasia grade 0 (CIN0).

The other five abnormal Pap results in women with persistent HPV came from women aged 30–49 years. A biopsy in one woman with HSIL found CIN3. Among three cases of low-grade squamous intraepithelial lesions (LSIL), one regressed spontaneously, and a biopsy in another found cervical intraepithelial neoplasia grade 3 (CIN3). One woman with persistent HPV in this middle-age group developed atypical squamous cells of undetermined significance (ASCUS).

Low-grade abnormal cytology also was seen in 10 HPV-negative women (7 with ASCUS and 3 with LSIL), but these lesions all regressed spontaneously.

The study suggests that canceling cervical screening for HPV-negative older women with normal Pap results would carry only a limited risk of missing cervical abnormalities or the development of slow-growing cervical cancer, Dr. Baay said.