FDA reviewing safety of Botox

The Food and Drug Administration is reviewing the safety of Botox and related drugs after receiving reports of respiratory failure and death in a small number of people treated with the medications.

The most serious cases involve off-label uses of the drugs in children. And the maker of Botox is now being investigated by the U.S. Department of Justice for inappropriate promotion of off-label uses. But the FDA says that there have been at least a few reports in adults who got the shots for cosmetic or other approved purposes.

Botox and related drugs use very low doses of botulinum toxin, a powerful natural poison, to paralyze overactive muscles. The shots are approved to treat not only wrinkles but also neck spasms, excessive sweating, crossed eyes, and certain other conditions. Some doctors also use the toxin, without FDA approval, for problems such as spasticity in the legs and arms.

Doctors have long known that in people who have pre-existing neuromuscular disorders the shots can trigger effects far from the injection site, including difficulty swallowing and breathing. The new reports suggest that those effects may occur in other people too. The FDA says that to date only a "small" number of hospitalizations or deaths have been reported to the agency, but there may be unreported cases. The FDA is considering a new warning for all botulinum-containing drugs, including Botox, Botox Cosmetic, and Myobloc.

Here's how to protect yourself:

• People taking or considering Botox for cosmetic reasons should think about the potential risks.


• Those taking or considering Botox or related drugs for medical reasons, especially off-label ones, should make sure that their doctor has considered alternatives. If the shots are necessary, ask your doctor to use the lowest effective dose.


• People taking the drugs for any reason should contact their doctor if they experience any of these warning signs: difficulty breathing, talking, or swallowing; muscle weakness; and shortness of breath.

This article first appeared in the May 2008 issue of Consumer Reports On Health

Are your kids drinking too much juice for their own good?

How much juice should your baby, your toddler, and your teen be drinking? Experts say less is more.

INFANTS. You shouldn't give your baby any juice for the first six months. Stick to breast milk or formula, which is much more nutritious, advises the American Academy of Pediatrics. After six months, if your little one is drinking from a cup, you can introduce some juice into his or her diet. Don’t give juice in a bottle, and never put your baby to bed with a bottle of juice—the sugar can lead to cavities. Four to six ounces a day is plenty. Or get your child to chow down on mashed-up or puréed whole fruits and vegetables.

TODDLERS AND SMALL CHILDREN. Fruit juice is sweet, and many kids will overindulge if given the chance. Don't give your tot a sippy cup full of juice, or a juice box, to walk around with all day. The prolonged exposure to sugar can cause dental problems. Instead, offer a cup of juice as a treat or a snack.

TEENAGERS. It can be hard to get a teenager to do anything you want, and drinking too much juice probably isn't a major worry. But at least one study has argued for a link between drinking more than 12 ounces of juice a day and obesity, though other research has indicated otherwise. One hundred percent juice is certainly better than soda, but try to encourage your kids to eat whole fruits instead and to limit juice to about 12 ounces a day.

Read more on ways to keep your child at a healthy weight.

Kids with ADHD should get a heart test before drug treatment

Children with attention deficit hyperactivity disorder should get an electrocardiogram, or ECG, before starting medication for the problem, an April American Heart Association statement recommends. The advice stems from growing evidence that the drugs commonly used to treat ADHD can elevate heart rate and blood pressure, and may increase the risk of sudden cardiac arrest. The latest estimates suggest that ADHD occurs in 5-7 percent of school-aged children in the U.S.

For most children with ADHD those effects appear to be minimal. But they can pose serious risks to children who have certain heart abnormalities. And the standard health exam most kids get from their doctor before starting the drugs may not reveal those abnormalities. Moreover, research suggests that children with ADHD may have a higher than average risk of heart problems.

For all those reasons, the new AHA recommendation calls for children and teens to have an ECG to measure the heart’s electrical activity and look for heart rhythm abnormalities before they start ADHD drugs. Those already taking the drugs should consider getting an ECG if they haven’t previously had one. Individuals with worrisome results on that test should be referred to a pediatric heart specialist before starting the drugs, and undergo frequent follow-up exams once they do.

Common ADHD drugs include dextroamphetamine (Dexedrine, Dextrostat, and generic), methylphenidate (Concerta, Ritalin, and generic), and Adderall, which is a combination of several amphetamines and is also sold as a generic.

The new concerns shouldn't stop parents and kids from seeking treatment for ADHD. But they do underscore the importance of thorough diagnosis and careful treatment. Indeed, as we have reported previously, many children and teens labeled as ADHD either do not have it or have only mild symptoms. They may not need medication at all. So be sure to get a second opinion if you have doubts.

For more about symptoms and medications to treat ADHD, read our free Best Buy Drugs report and our treatment ratings (subscribers only) on the condition.

—Joel Keehn, senior health editor

‘Natural’ doesn’t necessarily mean better or safer

All kinds of products are labeled natural these days, from chicken and soda to cosmetics and oven cleaners. But sometimes that natural claim can be misleading. For one thing, not all natural ingredients are the breath of fresh air you're looking for. Take carminic acid, a red dye extracted from pregnant scale insects; citric acid, made from fungus fermentation; and gelatin, made from the bones of livestock. And not all natural ingredients are benign.

Some herbal ingredients like d-limonene from citrus oils and sodium lauryl sulfate, derived from coconuts, can irritate to your lungs and skin. Even worse, there are no rules covering personal-care products, processed foods, or cleaners that use the natural label. So companies are free to slap on the label without any guidelines. The natural label on fresh food is also questionable; government regulations cover only meat and poultry. The Department of Agriculture can hold a company accountable, but no government or other agency verifies that food and other products are made from natural ingredients.

What you can do
Next time you see a natural label, check out the ingredient list. In processed foods like natural soda, for example, you might find high-fructose corn syrup, a chemically made sugar. Look instead for sodas that use cane sugar. You may also find heart-unhealthy partially hydrogenated oils (trans fats, which can be chemically made from oil) in natural snack foods and bread. Look for healthful, natural oils like olive oil and safflower oil in the ingredients list.

What’s in your medicine bottle? Your prescription may not be what the doctor ordered!

Just last week, two patients asked me how they could tell if they were getting the right drug. Their pharmacy benefits plan had mailed them their refills, but the drugs looked totally different. In the case of my migraine patient, Leslie, 80 milligrams of Inderal® was now a blue capsule whereas in the past it had always been a yellow tablet. "How do I know if I’m getting the right thing?" she asked.

It's a good question and consumers have a right to be concerned. Years ago when my brother developed bronchitis, he was given a script for the antibiotic Vibrax® (a drug no longer prescribed) by our family physician. By the time he had finished the bottle, his cough was worse and he was even more run down, so the doctor's office phoned in another course of treatment. It wasn't until my brother picked up the pills from the pharmacy and saw that they looked different that he discovered that he had been taking Librax®, a sedating medication, by mistake—the "V" on the original prescription had been mistaken by the pharmacist for an "L."

Thirty years later, more than three-fourths of physicians are still scribbling prescriptions and look-alike and sound-alike errors are still being made. Although digital tools such as handheld prescribing devices and electronic health records are now available, only about 20 percent of us use them, and alas, our handwriting has not improved.

Hands-only resuscitation replaces mouth-to-mouth

It's a disturbing fact that only a third of adults who collapse from cardiac arrest get the emergency first aid that can help them survive. Cardiopulmonary resuscitation (CPR) usually involves giving a person mouth-to-mouth while pressing hard on the center of the chest. The procedure, which can be performed by any adult, is intended to maintain a flow of blood and oxygen to the heart and brain until emergency medical help arrives, and it doubles someone's chances of surviving. Yet bystanders are often worried about making things worse, and many people don't like the idea of giving mouth-to-mouth.

Now, a round-up of the research on cardiac arrests, published by the American Heart Association (AHA), says that, in many cases, using chest compressions alone (called "hands-only CPR") is likely to work just as well as traditional CPR using mouth-to-mouth. And bystanders may also find it easier to carry out.

According to the AHA, anyone who sees an adult suddenly collapse should:

• Call 911
• Push hard and fast on the center of the person's chest.

The AHA points out that an adult who collapses and isn't responding is very sick, so there's very little chance of making things worse. It's fairly common to break a rib while doing CPR, but without urgent help, a person in cardiac arrest is almost certain to die.

You need to continue with CPR until emergency services arrive. Chest compressions are hard work, so if there's someone around who can help, swap over as you get tired. If you're on your own, just do the best you can.

There are still some instances where traditional CPR, including mouth-to-mouth, is better. Adults who are found already unconscious, children, victims of drowning or people with breathing problems may be better off getting traditional CPR. If you've been taught how to give mouth-to-mouth resuscitation, and are confident you can do it, you can still do CPR in the way you were trained. But any attempt at CPR is better than nothing.

If you see someone collapse, call 911, then start pushing hard and fast on the center of the person's chest. If you've been trained in CPR that includes mouth-to-mouth, and you're confident you can do it, add 2 breaths for every 30 chest compressions.

—Philip Wilson, patient editor, BMJ Group

ConsumerReportsHealth.org has partnered with The BMJ Group to monitor the latest medical research and assess the evidence to help you decide which news you should use.

Q&A: Liquid vitamins—better absorption?

My wife pays a premium for liquid vitamin and mineral supplements, which are supposedly better absorbed by the body. Are they worth the cost? —D.P., Sacramento, Calif.

Probably not, unless your wife has trouble swallowing solid supplements. In theory, liquid supplements should be better absorbed by the stomach since they’re already dissolved. But there has been little research to substantiate that idea. And at least some evidence has shown no meaningful difference. A small study in adults over age 65, for example, found they absorbed calcium from solid supplements just as well as calcium from fortified milk or orange juice. And adults older than 50‚ who may lack sufficient amounts of a stomach chemical needed to fully extract vitamin B12 from food, readily absorb the vitamin from pills. So the better absorbability (in theory) from liquid supplements most likely doesn’t justify the added cost.

Read up on supplements to avoid (free), and see our Natural Medicine Ratings (subscribers only) for more facts on vitamins and minerals.

This article first appeared in the September 2006 issue of Consumer Reports On Health.

Help yourself: Learn how to rate and manage pain

Pain is the main complaint for about 40 percent of patients visiting primary-care doctors with roughly half of the people with chronic or recurrent pain failing to get adequate relief. In many ways pain remains a medical mystery, but here’s what to do for occasional, severe, and recurrent pain:

Self assess. First, assess how bad the pain is. Rate it on a scale of 0 (no pain) to 10 (the worst pain you could imagine). For pain that you rate 5 or less, start by self-treating with nondrug measures. For example, use heat to help ease back pain or cramps. You can also use over-the-counter pain relievers, which typically suffice for this level of pain.

How to choose an over-the-counter. Choose a drug based on the type of pain and your risk factors. Acetaminophen (Tylenol or generic) is often a good option. At recommended doses it's reasonably safe and effective for most people. People who drink heavily or have a liver disorder should avoid acetaminophen, since it's toxic to the organ. Ibuprofen and naproxen are often good over-the-counter choices if acetaminophen isn't enough. They not only ease pain but also quell inflammation. Both drugs are probably safer than aspirin, which poses a higher risk of bleeding. And while long-term use of any NSAID poses serious gastrointestinal and possibly coronary risks, the short-term use of recommended doses is generally safe for most people who don’t have heart, kidney, or stomach problems.

Severe-pain solutions. If you rate your pain at 6 or higher, it doesn’t improve with nondrug steps and OTC drugs, or it lasts longer than a few days, see your doctor. He or she might suggest a prescription NSAID, because a different or stronger formulation may yield additional relief. Another approach can be a prescription opioid such as oxycodone (Oxycontin and generic). You or your doctor might resist using such drugs because of addiction concerns. But physical dependence typically requires several weeks of use, and psychological dependence in patients with acute or severe pain is unlikely because they rarely experience euphoria from the drugs.

Medications that pair an opioid with acetaminophen, aspirin, or ibuprofen may be an even better choice. Those can provide greater relief, since the two ingredients work in different ways, and they reduce the risk of side effects because the combination permits smaller doses of each.

Recurrent pain. Even when the pain is relatively mild, chronic or recurrent pain from arthritis, headaches, or other sources can seriously interfere with everyday activities. Since chronic pain often ebbs and flows, rating your discomfort on the 0 to 10 pain scale can help you decide, day to day, how to manage the problem.

For more information, see Consumer Reports’ Best Buy Drug report on opioids.

Opioids for relief of chronic pain? Try less risky treatments first

Chronic pain is one of medicine's conundrums. It has a myriad of causes, including injuries that fail to heal properly, nerve damage, and aging joints. And sometimes it seems to arise for no apparent reason. It's notoriously tough to treat.

As a result, people with chronic pain face a host of frustrations and often try many treatments and painkillers before finding relief. A new report from the Consumer Reports Best Buy Drugs project offers fresh guidance on using the strongest of these painkillers—called the opioids—to treat chronic pain.

This 20th Best Buy Drug report compares 12 opioids. We've chosen four generics as Best Buys for people who have chronic pain and whose doctors have concluded that an opioid is necessary. Based on their relative low cost, the evidence for effectiveness, safety, side effects, and dosing convenience and flexibility, the Best Buys are:

• Codeine plus acetaminophen
• Morphine extended release
• Oxycodone extended release
• Oxycodone with acetaminophen

These four medicines have a long track record and provide good value. They range widely in monthly cost, depending on dosing regimen. But most low-dose regimens will run you less than $150 a month or so.

There's no reason to take the brand-name versions of these drugs—Tylenol #3 or #4, MS Contin, OxyContin, or Percocet—or any opioid for that matter.

Evidence links the long-term use of opioids to some unpleasant side effects, such as loss of interest in sex and impaired sexual function; a decline in immune function; and an increase in the body's sensitivity to pain.  Also, the opioids carry the risk of being addictive and are prone to abuse and misuse. In people who genuinely need them to control moderate to severe pain, addiction is rare, however.

Our report finds that many consumers believe their chronic pain warrants the strongest of pain relievers. But the evidence actually shows that everyday pain relievers, when used in moderate to high doses, can be just as effective as the opioids against many forms of chronic pain—like back pain, osteoarthritis, and recurring muscle pain. And they are a lot safer.

If you suffer from chronic pain we also advise you to talk with your doctor about non-drug measures. Several, including cognitive behavioral therapy, exercise, spinal manipulation, and physical rehab programs, have been shown to ease pain and/or improve quality of life.

The bottom line: don't use opioids until you have tried other, less risky, pain relievers first, and failed to get adequate relief. Those include acetaminophen (Panadol, Tylenol, and generic), non-steroidal anti-inflammatory drugs (the so-called NSAIDs), such as ibuprofen (Advil, Motrin, and generic) and naproxen (Aleve, Naprosyn, and generic), or other non-opioid prescription painkillers.

To find out more about the uses and side effects of the drugs in this class, read our FREE Consumer Reports Best Buy Drugs report.

—Steve Findlay, managing editor, Consumer Reports Best Buy Drugs

5 ways to cut costs while staying healthy

The government may not want to use the "R" word, but there’s no question that the economy is in trouble. It's affecting all of us and causing us to tighten our belts. When it comes to medical care, telltale signs come early. Reports of increasing numbers of elective surgeries have been attributed to fear of potential loss of insurance coverage, similar to when rumors of company cutbacks surface. Routine and preventive care visits decline, and in my practice, I see more patients forgoing referrals to physical therapy because of the frequent co-pays.

Taking care of your health during a recession poses quite a challenge. If you’re healthy, you want to stay that way, and if not, you want to make sure that your treatment is not jeopardized. So what can you trim without sacrificing quality? Consumer Reports has a wealth of information on how to get the best value when it comes to your health.

• Ask your doctor about pill splitting. It can save money because pharmacies often charge the same amount for a particular drug regardless of its dose. There’s no harm in splitting pills as long as your doctor agrees with the idea, you learn how to do it properly, you split only pills that are scored, never split extended- or continued-release tablets, and use a safe pill splitting device, available at most pharmacies for around $5.
• Look into a prescription assistance program. If you need medicines (especially for a chronic condition) and have no health insurance, limited insurance, or lack drug coverage under your current health insurance policy you may qualify for assistance.
• Consider switching to a generic prescription drug. Consumer Reports Best Buy Drugs can help you find the most safe and effective drug for your condition and give you the best value for your health. Not only are generic medications proven and more affordable alternatives, but the newest brand name drugs have less of a track record for safety.
• Put your fancy gym club membership on hold. As the Consumer Reports survey on health clubs showed, you can pay up to $95 per month for name brand chains and still not get a quality experience. Try out your local Y or community center—which got higher marks in our survey than most big chains—or change some habits: take the stairs, park at a distance, walk the dog. As an inexpensive pedometer shows, those steps soon add up.
• Shop smart. Although it’s tempting to reach for inexpensive processed foods on the supermarket shelf, resist the temptation. It’s important to remember to eat healthy foods including fresh fruits and vegetables. Warehouse club supermarkets fared very well in terms of price on the 2005 Consumer Reports Grocery Store Shopper Survey of 24,000 respondents. Those that gave our readers the biggest bang for the buck (subscribers only) were Aldi, WinCo, Trader Joe’s, Market Basket, Cost­co, Shoppers Food Warehouse, Wal-Mart, and Stater Bros. (These chains are a good choice if your top concern is low prices, and service and the quality of meat, produce, and fresh-baked goods are less important.) Use the FDA’s free nutritional label training program to find information that will help you stay healthy by selecting the right foods when you shop.

—Orly Avitzur, M.D., medical adviser to Consumers Union

Smart shopping for hospital care

Want to know which hospital is best suited to treat your medical condition? Or would you simply like to know how other patients really felt about their care while being treated at your local hospital? New data released last week can help you decide without having to rely on word-of-mouth recommendations or other biased information.

A new consumer Web site, Hospital Compare, offers data from about 2,500 hospitals that care for adult patients, which can allow you to make an informed choice about hospital care.

The information, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), allows consumers to see how frequently hospitals offer treatments for heart attack, heart failure, pneumonia and surgical patients. The HCAHPS information was collected through surveys given to patients after they received hospital care. Among the 27 survey topics patients responded to were:

• Communication with doctors and nurses
• Cleanliness of the hospital
• Pain management
• Information received when being discharged from the hospital
• Willingness to recommend the facility to others

Information is to be updated quarterly and data from most of the nation’s hospitals is to be appear on the site by year’s end.

Hospital Compare is the result of a cooperative effort among members of the Hospital Quality Alliance (HQA), the Centers for Medicare and Medicaid Services, which is a part of the U.S. Department of Health and Human Services.

In presenting the site to members of the media, Michael O. Leavitt, U.S. Health and Human Services secretary said, “This is not about eliminating anyone. This is about improving everyone.” And it’s also about informing everyone.

Check it out for yourself at www.HospitalCompare.hhs.gov.

—Gayle T. Williams, deputy editor

8 secrets of successful dieters

There's no question that sticking to a do-it-yourself diet plan is never easy. We rated popular diet books and took away eight practical, evidenced-based strategies for DIY dieters who want to lose weight on their own. Pick one—or two or three that work for you, and start losing!

1. Start right. While dieters might prefer to save calories by skipping breakfast, eating a substantial morning meal is recommended by every diet book we analyzed. Seventy-eight percent of the successful losers at the National Weight Control Registry say they eat breakfast, typically some cereal and fruit. The Registry, which enrolls people who can document that they have lost more than 30 pounds and kept it off for at least a year, has more than 5,000 members.

2. Choose (and limit) your fats. Many diet experts have backed away from avoiding fats, though this traditional approach is still used by very low-fat plans such as Dean Ornish’s “Eat More, Weigh Less” and the diet endorsed by the Pritikin Longevity Center.

Some research shows that a very low-fat diet can slow the progression of heart disease and breast and prostate cancer. But the dropout rate from that type of diet is high. Scientists now distinguish good fats from bad, based on copious evidence about their effect on blood cholesterol. Most of the popular diet books we analyzed warn against eating "bad" fat, including trans fats created when vegetable oil is hydrogenated, and the saturated fats from meat and dairy sources. Good fats include olive and other monounsaturated oils, nuts, avocados, and omega-3 oils from seafood and plant sources.

But good or bad, all fats have big calorie counts. They contain 9 calories per gram, compared with 4 per gram for carbohydrates and protein. The diet menu in “Eat, Drink, and Weigh Less” recommends liberally consuming healthy fats. But when we analyzed the meal plan, it totaled 1,910 calories per day, about 40 percent of them from fat, which would make weight loss unlikely for many people.

3. Eat healthfully—but sparingly. Backed by a growing body of research, nutritionists have come to a rough consensus on what a truly healthful diet looks like: Eat plenty of fruits and vegetables, and some lean meat and fish, healthy fats, and whole grains. And minimize refined grains, potatoes, full-fat dairy products, and added sweeteners--especially in the form of soft drinks. Studies of large populations the world over have shown that this diet reduces the risk of heart disease, diabetes, and certain cancers.

With minor variations, all the diet books we evaluated recommended some version of this eating plan--and their uniformly high ratings for nutrition reflect that. But they didn’t seem "willing to emphasize calories, or tell people to 'eat less,'" said Rena Wing, Ph.D., a professor in the department of psychiatry and human behavior at Brown University's medical school and a founder of the National Weight Control Registry.

The bottom line is that no matter how "healthy" your diet is, you still have to restrict quantities to lose weight. "The Best Life Diet," which got top marks from our reviewers, provides detailed instructions on proper serving sizes for many different types of foods.

4. Crank up the activity. To control weight from exercise alone requires a devotion that few nonathletes can summon: 60 to 90 minutes a day of moderate to vigorous exercise. But increasing the time you spend out of your chair—in formal exercise and activities such as housework and yard work—helps you burn at least some calories. And an active lifestyle will help you maintain your weight loss. National Weight Control Registry participants report doing about an hour a day of moderate-intensity exercise, like brisk walking. Of the books we evaluated, "You on a Diet," "The Best Life Diet," and "The Abs Diet" got high marks for their clear and detailed sections on exercise.

5. Consider cutting carbs. Virtually all diets restrict or eliminate "bad" highly refined carbs such as white bread, cookies, chips, and soft drinks. But a wholesale cutback on grains, fruits, and the sweeter vegetables, such as beets and carrots, was first popularized by the Atkins diet. Recent research has found that for up to a year, some people can indeed safely lose weight on Atkins. In the most recent study, published in the March 7, 2007, Journal of the American Medical Association, 311 overweight women were randomly assigned to one of four diets: Atkins, Zone, Ornish, and a control group on a traditional low-fat menu plus various behavioral strategies. On some measures, Atkins dieters came out ahead. "They had better triglyceride lowering than Zone dieters, better HDL raising than Ornish, and better blood-pressure lowering than all three," said Christopher Gardner, Ph.D., assistant professor of medicine at Stanford University, director of the study. But while Atkins dieters lost modestly more weight than Zone dieters, at 12 months their weight loss was similar to those on the Ornish or control diet.

Very low-carb diets are not for everyone. As Gardner points out, at least some participants lost 30 pounds and kept it off for a year on all the diets in the study. Successful losers in the National Weight Control Registry overwhelmingly report that they consume plenty of carbs while restricting fat and portions.

6. Fill up on low-density foods. One way to spare calories and still eat a satisfying amount of food is to focus your diet on foods that have fewer calories per bite, or low "energy density." Starting your meals with a low-calorie soup or salad and eating main dishes that are full of vegetables and fruits are the main tactics of the low-density diet.

Using government food consumption surveys, researcher Barbara Rolls has shown that people who eat a low-energy-density diet consume hundreds fewer calories per day than those with a high-density diet, yet eat a greater amount of food. And in research on volunteers in her Penn State lab, Rolls has found that consuming a low-density diet helps people lose weight and keeps them thinner. "Volumetrics," based on this research, has now been studied in clinical trials and finished at the top of our diet Ratings.

Whether they say so explicitly or not, many of the other diets and books we evaluated recommend strategies to reduce the energy density of food. People on the Weight Watchers point system, for instance, soon learn that if they spend too many of their daily point allotment on calorie-dense foods, they’ll go to bed hungry. “The Sonoma Diet” sternly limits dieters to no more than 3 teaspoons of olive or canola oil per day but permits unlimited quantities of low-calorie-density vegetables such as broccoli, spinach, and tomatoes. The Ornish diet, which bans fats almost completely, had the lowest energy density of any that we studied.

7. Bring back the scale. Many of the books we reviewed discourage the practice of daily, or even weekly, weigh-ins, at least in the initial stages of a weight-loss diet. But 75 percent of National Weight Control Registry members weigh themselves at least weekly. "They remain vigilant about their weight loss," Wing said. "It seems likely that if they gain a pound or two, they take steps to lose it before it can accumulate."

8. Bore yourself thin. Though many books promise readers they’ll be eating a huge variety of foods, in practice they limit variety of high-calorie foods. "The South Beach Diet," "The Sonoma Diet," and "UltraMetabolism" were especially restrictive in their severe initial phases.

Since variety stimulates the appetite, the more monotonous your diet, the less you’ll eat. So steer clear of buffet tables, which can be the dieter’s worst enemy.

To learn more, read what optimistic dieters say about losing weight, watch our free video on diet ratings, and check out our diet book ratings (subscribers only).

Poll: Most Americans don’t know they can report bad drug reactions

A new Consumer Reports poll shows that one in six Americans who have ever taken a prescription drug experienced a side effect serious enough to send them to the doctor or hospital, but the majority of consumers don't know they can report these side effects to the FDA, which is responsible for tracking drug safety problems.

To help make the public aware of the FDA's reporting program for drug side effects—known as MedWatch—Consumers Union today gave the FDA a petition signed by nearly 56,000 consumers asking that a toll-free number and website be included in all TV drug ads so people can easily report their serious side effects to the agency.

Of the consumers polled, eight in 10 (81 percent) said they had seen or heard an advertisement for prescription drugs within the past 30 days. Among them, virtually all—98 percent—viewed an ad on television. When asked if they think prescription drug advertising should include information to report an adverse drug reaction to the FDA, 87 percent of consumers said TV ads should contain the information, and 90 percent said print ads should do the same.

For more information, read the poll and the petition to the FDA, see Adwatch—our video series on the facts behind the drug ads, and watch our animated drug safety video, "The Drugs I Need."

Are adults snoozing while kids are "snusing?"

I recently wrote a blog about hookah smoking—prompted by my sixteen-year-old son—about the practice among teenagers. When he read it online, his blasé response was that it was "so yesterday's news." The preferred method of tobacco in school these days, he said, is smokeless tobacco. In addition to chewing tobacco which comes in the form of loose leaf, plug or twist, the current rage is a less conspicuous product called "Snus", a non-chew, no-spit oral tobacco that's stuffed between the lip and gum.

One of the more popular brands, Camel Snus, manufactured by tobacco giant RJ Reynolds, is sold in tea-bag like pouches about the size of a lozenge. Teachers can't easily detect the pouches, so kids can fly under the radar when they use it in school. Even so, the habit has become so prevalent that there have been recent announcements on the loudspeaker at my son’s high school reminding students that smokeless tobacco is a code of conduct violation. When I asked my son how common it was, he guessed that about 10 percent of the boys in his class were using it.

Although teens have been known to exaggerate, his estimate is actually under the national average. A Morbidity and Mortality Weekly Report released in June 2006, revealed that the prevalence of smokeless tobacco use is closer to 14 percent among high school-aged boys and a little over 2 percent among girls. The rate varied widely across states with 4.4% usage among male students in Maryland and 26.5% in West Virginia. Overall, the percentage was highest among white male students (17.6%) and rose each year from 9^th to 12^th grade among male students.

According to the CDC, smokeless tobacco carries four dangerous health effects:

• It contains 28 cancer-causing agents (carcinogens).
• It’s a well- known cause of cancer, increasing the risk of cancer of the mouth.
• Oral health problems strongly associated with smokeless tobacco use are leukoplakia (a lesion of the soft tissue that consists of a white patch or plaque that cannot be scraped off) and recession of the gums.
• Smokeless tobacco use can lead to nicotine addiction and dependence and adolescents who use smokeless tobacco are more likely to become cigarette smokers.

It’s quite possible that kids are unaware of these warnings. But last week, a 24-year old patient told me that he wished he had known more about the risks when he was using chewing tobacco in high school. When he tried to quit after six years, he found it impossible. He said that coaches and teachers had turned a blind eye to the habit, and that no one warned him that it could be harmful.

Several tobacco companies have banked on the lack of attention paid to smokeless tobacco—the five largest smokeless tobacco manufacturers spent a new record of $250.79 million on smokeless tobacco advertising and promotion during 2005 alone. Despite the 1998 Smokeless Tobacco Master Settlement Agreement—a legal settlement between the states and the tobacco companies prohibiting tobacco companies from taking "any action, directly or indirectly, to target Youth... in the advertising, promotion or marketing of tobacco products."—smokeless tobacco companies have continued to advertise in magazines with high youth readership. According to a new report published in the March 2008 issue of the American Journal of Public Health, magazines with high youth readership accounted for roughly 47 percent of all smokeless tobacco expenditures.

Tobacco-free kids, a non-profit organization dedicated to reducing tobacco use, advises that smokeless tobacco companies in the United States have a long history of creating new products that appeal to kids and marketing them aggressively. The U.S. Smokeless Tobacco Company markets candy-flavored spit tobacco including berry blend, mint, wintergreen, apple blend, vanilla blend and cherry. Indeed, it has been alleged that manufacturers have developed flavored products with lower nicotine concentrations to get users early so that they become dependent and seek out products with a higher nicotine concentration.

This so-called "graduation strategy" worked with my patient. By the time he had graduated from college, he had graduated to cigarettes.

Read our free facts about smoking and our complete Treatment Ratings and Natural Medicine Ratings (subscribers only) on how to quit .

—Orly Avitzur, M.D., medical adviser to Consumers Union