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RESEARCH: Jill M Ellis, Hooi Kuan Tan, Ruth E Gilbert, David P R Muller, William Henley, Robert Moy, Rachel Pumphrey, Cornelius Ani, Sarah Davies, Vanessa Edwards, Heather Green, Alison Salt, and Stuart Logan Supplementation with antioxidants and folinic acid for children with Down’s syndrome: randomised controlled trial BMJ 2008; 336: 594-597 [Abstract] [Full text]

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Daily food and micronutrient supplementation

Dewan S. Billal, Ph.D, Muneki Hotomi, MD, Ph.D, Professor Noboru Yamanaka, MD, Ph.D   (22 February 2008)

Were sufficient antioxidants employed in this study?

Steve Hickey PhD, Hilary Roberts PhD, Andrew Hickey   (26 February 2008)

The first hopefully of many

Andrew N. Williams   (28 February 2008)

Lack of endogenous antioxidants and appropriate dose-schedule

Kedar N. Prasad, 14 Galli Drive, Novato, CA 94949   (1 March 2008)

Supplementation with antioxidants and folinic acid for children with Down’s syndrome

Dr Hadi Meeran Hussain,M.D,M.P.H, Dr Mujeeb Ur Rehman Abid Butt M.D,MRCP   (6 March 2008)

Nutritional Interventions and the Potential for Type II Errors

Gregory A Plotnikoff   (14 March 2008)

Antioxidants under the scrutiny of science

Carlos K B Ferrari, Eduardo L França, Adenilda C Honorio-França, Paula C S Souto. Federal University of Mato Grosso (UFMT), Instituto Universitário do Araguaia   (21 March 2008)

Down's Syndrome and blood flow.

Les O. Simpson   (2 April 2008)

Fortified Baby Formula

Peter Elliott, High Wycombe. HP11 1PW   (19 June 2008)

Daily food and micronutrient supplementation 22 February 2008
Dewan S. Billal, Ph.D, postdoctoral Fellow, Microbiologist Deapartment of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japa, Muneki Hotomi, MD, Ph.D, Professor Noboru Yamanaka, MD, Ph.D Send response to journal: Re: Daily food and micronutrient supplementation	Sir-Jill M Ellis and colleagues1 provides a randomized controlled trial regarding supplementation with antioxidant and folinic acid for children with Down's syndrome in UK. The study revealed that supplementation with antioxidant and folinic acid had no effect on Down's syndrome diseases. Recently many studies are emphasizing supplementation of child and maternal food with micronutrients to reduce the maternal and child mortality all over the world especially in the developing countries. Although micronutrients; vitamin A, zinc, iron and iodine deficiencies represented 11.13% death of children under 5 years, and a combined 10.3% of global DALYs al over the world2. There is a proverb that prevention is better than cure. Dietary intake of protein and micronutrient might be improved maternal and children health rather than supplementation. We need to change habit of our dietary. Food supplementation benefits the food industries for more profit rather than total health all over the world. In a study showed that small fish like mola are rich in calcium, vitamin A, iron, and zinc, and which can meet the annual vitamin A recommendation of 2 million children in Bangladesh, and a traditional daily meal with the iron-rich fish trey changwa plieng can meet 45% of the daily median iron requirement of Cambodian women3. In conclusion, all women and children in the world can get optimal essential nutrients and micronutrients if the families have the capability of buying the balance food during their pregnancy and childhood respectively. We should change our habitat about dietary, and for that education, socioeconomic status and awareness are ahead of all. We declare that we have no conflict of interest *Dewan Sakhawat Billal,Ph.D, Muneki Hotomi, MD,Ph.D, Noboru Yamanaka, MD,Ph.D, billalds@wakayama-med.ac.jp Division of Infection and Immunity research Center, Department of Otolaryngology-Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan References 1. Ellis JM, Tan HK, Gilbert RE, Muller DPR, Henley W, Moy R, et al. Supplementation with antioxidants and folinic acid for children with Down¡¯s syndrome: randomised controlled trial. BMJ 2008 doi: 10.1136/bmj.39465.544028.AE. 2. Black RE, Allen LH, Bhutta ZA, et al. for the Maternal and Child Undernutrition Study group. Maternal and child undernutrition: global and regional exposure and heath consequences. Lancet 2008; 371:243-60. 3. Roos N, Wahab MA, Chamnan C, Thilsted SH. The role of fish in food -based strategies to combat vitamin A and mineral deficiencies in developing countries. J Nutr 2007;137:1106-9. Competing interests: None declared
Were sufficient antioxidants employed in this study? 26 February 2008
Steve Hickey PhD, Lecturer FCET, Staffordshire University, England, ST16 9DG, Hilary Roberts PhD, Andrew Hickey Send response to journal: Re: Were sufficient antioxidants employed in this study?	The paper by Ellis et al. illustrates a widespread problem in medicine: failure to understand the actions of antioxidants in disease. The study provides little evidence on the question of whether subjects with Down’s might benefit from dietary antioxidants, because, as the authors themselves suggest, the low doses of supplements “may have been inadequate to affect biochemical pathways". The disease mechanism for Down’s syndrome arises from an increase in the activity of redox active enzymes. This leads to excess hydrogen peroxide, which causes oxidation and free radical damage in the brain. By definition, antioxidants can prevent such damage, thus potentially forming an appropriate treatment. The crucial research question is whether the appropriate dietary antioxidants can be given safely in doses sufficient to influence the pathology of the disease. In order to influence brain pathology, dietary substances must enter the brain in sufficient concentration to act as antioxidants. The levels of primary antioxidants (vitamins C and E) used in this study were similar in magnitude to the corresponding recommended dietary allowance (RDA) levels. The subjects were young children, who would normally require lower doses than adults. However, it is important to remember that the antioxidants were intended to treat disease and, hence, we are in the realms of pharmacology rather than nutrition. Claims for vitamin C as an antioxidant therapy involve very high doses. According to popular belief, one gram is a high dose. Contrary to this, prevention of colds (80-90%) requires doses of 10g per day or above; treatment calls for doses an order of magnitude larger. So, for example, claims for treating a cold effectively (Klenner, Cathcart, and others) [1] involve doses in the range 30g-150g per day.[2] Below these intakes, clinical effects are smaller and are more variable.[3] The 50mg daily doses of vitamin C used in this study are substantially below pharmacological levels. Assuming a weight of 8 kg for a 7 month old child, a minimal therapeutic ascorbate dose of 140 mg/kg gives 1120 mg, i.e. approximately one gram. Thus, the dose of ascorbate employed in this study was approximately 1/20th of the minimum required. Similar considerations apply to the other nutrients. The short half-life of vitamin C means dosing frequency is also important (6 hourly or less)[2]. Subjects took 100mg of “vitamin E”; the form was not specified, although blood á-tocopherol levels were measured. Vitamin E is not a single molecule, but a range of substances that can prevent lipid oxidation in vivo. Numerous different molecules show vitamin E activity, particularly the tocopherols and tocotrienols; each has a specific pharmacology and distribution in the body. Synthetic forms, such as dl- alpha-tocopherol, are often used in studies, though they are far less effective than the naturally occurring forms. To act as an antioxidant, vitamin E is required in higher intakes than previously realised.[4] Indeed, Balz Frei, of the Linus Pauling Institute, has described almost all clinical trials of vitamin E as “fatally flawed” because they used an insufficient dose of vitamin E.[5] To act as an antioxidant in vivo, an adult requires between 1600 and 3200 IU. Assuming 40 IU per kg, a minimum dose of about 320 IU of a high quality, natural form of vitamin E would be required for a 7-month-old child. The 100mg (synthetic?) dose employed may not act as an effective antioxidant in the brain, particularly in the absence of high levels of vitamin C. The study employed folinic acid (0.1mg), selenium (10 ìg), zinc (5 mg), and vitamin A (0.9 mg) at low doses. Ellis et al. note that the response to folate may be enhanced by adding selected nutrients (methionine, methyl B-12, thymidine, and dimethylglycine). The specific forms of the nutrients employed was not made clear, for example forms of selenium, such as sodium selenite and methylselenocysteine, differ in pharmacology and antioxidant properties. Although we use vitamins C and E to address the main research problems, the selection and dosage of all nutrients in this study was suboptimal. Biochemical measures in the study suggest that supplementation did not affect oxidative stress levels; this supports our suggestion that the doses employed were too low to act as in vivo antioxidants in these subjects. The pathology of Down’s syndrome has a specific oxidative mechanism. The laws of physical chemistry suggest there is little point carrying out studies using doses of antioxidants that are too low to provide the intended action: prevention of oxidation in the brain. It is possible to select suitable dietary antioxidants that can enter the brain and provide them in sufficient doses to have the desired biophysical effect. This study did not address the role of antioxidants in Down’s, as it did not use sufficient nutrients to act in vivo. Moreover, the unfortunately common propensity to give insufficient and inappropriate nutrients in trials is potentially harmful. Reports based on low intakes may prevent subjects with Down’s and others from gaining benefits which are obscured by these unsuitable studies. [1] Cathcart R.F (1985) Vitamin C, the nontoxic, nonrate-limited antioxidant free radical scavenger, Medical Hypothesis, 18, 61-77. [2] Hickey S. Roberts H. (2004) Ascorbate: The Science of Vitamin C, Lulu press. [3] Cathcart R.F. (1981) Vitamin C, Titration to Bowel Tolerance, Anascorbemia, and Acute Induced Scurvy, Medical Hypothesis, 7, 1359-1376. [4] Roberts L.J. Oates J.A. Linton M.F. Fazio S. Meador B.P. Gross M.D. Shyr Y. Morrow J.D. (2007) The relationship between dose of vitamin E and suppression of oxidative stress in humans, 1388-1393. [5]Frei B. (2007) in Vitamin E Trials 'Fatally Flawed', ScienceDaily, Sep. 26. Competing interests: None declared
The first hopefully of many 28 February 2008
Andrew N. Williams, Consultant community Paediatrician Northampton General Hospital NN1 5BD Send response to journal: Re: The first hopefully of many	I was really pleased to see this paper in the BMJ. The fact that such a study, funded through medical charities for a specific disabled group, was undertaken and published within such a journal is a significant milestone in itself in the history of disability. I am still a relatively young medical practitioner, but when I was a medical student in the 1980’s I recall a child with Down's syndrome with a cardiac defect who many years previously, had not been put forward for corrective cardiac surgery. The reason I recall from what the family told me was not on grounds of overwhelming technical difficulty but solely on the fact of the child being a Down’s patient and sadly this was felt to be acceptable practice at the time. This first opened my eyes to the discrimination suffered by the disabled. Fortunately society's attitudes concerning cardiac surgery for children with Down's syndrome have moved on, but unfortunately discrimination towards the disabled still exists. I would like to hope that this excellent study is the first of many in the area of paediatric disability, but hopefully with more positive results. Competing interests: None declared
Lack of endogenous antioxidants and appropriate dose-schedule 1 March 2008
Kedar N. Prasad, Chief Scientific Officer Antioxidant research Institute, PMC, 14 Galli Drive, Novato, CA 94949 Send response to journal: Re: Lack of endogenous antioxidants and appropriate dose-schedule	The manuscript entitled , "Supplementation with antioxidants and folinic acid for children with down's syndrome:randomized controlled trial", by Dr. Ellis et al is a well designed study in order to evaluate the efficacy of antioxidants alone or in combination with folinic acid.The antioxidant preparation used in this study lacks endogenous antioxidants such as alpha-lipoic acid, n-acetylcysteine (a glutathione-elevating agent),co-enzyme Q10, and l-carnitine.The inclusion of these endogenous antioxidants is necessary, because in most neurological diseases such as Alzheimer's disease, one of the consistent findings in the autopsied brain samples are low levels of glutathione and mitochondrial defects.Glutathione is very suceptible to oxidative stress,and is considered the most important intracellular antioxidant for protecting against oxidaitve damage. Coenzyme Q10 is an essenial co-factor for generating ATP (adenosine triphospahte, but it also acts as a weak antioxidants, and is capable to re-cyling vitamin E (1). An appropriate dose-schedule is also important in order to increase the efficacy of antioxidant preparation.The biological half-lives of antioxidants vary from about 6-10 hours depending upon their solubility in water or lipid.In addtion, diffrences in the levels of antioxidants induced a marked difference in the expression of gentic profiles (2). Therefore, taking antioxidants once a day as was used in this study, may cause high levels of fluctuations in the levels of antioxdants that could create celluar stress over a long period of time. Thus, the inclusion of endogenous antioxidants, and taking antioxidant preparation twice a day could have improved its efficacy in the management of Down's syndrome. References 1.Prasad, KN,Cole, WC and Prasad, KC. Risk factors for Alzheimer's disease: role of multiple antioxidants, non-steroidal anti-inflammatory and cholinergic agents alone or incombination in prevention and treatment.J. Am. Coll. Nutr. 21:506-522, 2002. 2.Prasad, KN. Antioxidants in cancer care: when and how to use them as an adjunct to standard and experimental therapies. Expert Rev anticancer Ther. 3:903-915, 2003. Competing interests: None declared
Supplementation with antioxidants and folinic acid for children with Down’s syndrome 6 March 2008
Dr Hadi Meeran Hussain,M.D,M.P.H, Department Of internal Medicine Combined Military Hospital,adul Rehman Road,Saddar,lahore,Cantt, Dr Mujeeb Ur Rehman Abid Butt M.D,MRCP Send response to journal: Re: Supplementation with antioxidants and folinic acid for children with Down’s syndrome	This study presents results of a clinical trial involving dietary supplementation of several antioxidant vitamins and related compounds in 156 children with Down syndrome (DS) (1). Supplementation consisted of daily, oral 10 ìg selenium, 5 mg zinc, 0.9 mg vitamin A, 100 mg vitamin E, 50 mg vitamin C, and 0.1 mg folinic acid (alone or in combination with the other supplements to address a functional folate deficiency), as well as a placebo. This began at 4 months (mean age) and continued for 18 months, at which time mental development, including language and psychomotor skills, was assessed, as were biochemical markers of oxidative stress and antioxidant effects. There was no evidence of benefit in any of the behavioral endpoints, a finding consistent with previous studies (2). Remarkably, no changes in biochemical markers of oxidative stress were noted, either. Oxidative stress is an established component of DS pathology (3) and triplication (trisomy 21) of SOD1 is thought to play a role (4,5,6). However, as in the case of Alzheimer disease (AD), evidence of an oxidative lesion contrasts with lack of strong evidence for clinical benefit of antioxidant supplements in established disease (7,8,9,10). Ellis and colleagues looked for reduction in markers of oxidative stress (red blood cell superoxide dismutase and glutathione peroxidase activities, and urinary isoprostane as a measure of lipid peroxidation), but found no effect, though vitamin E levels in blood were consistently high in the vitamin-treated group. This does not weaken the conclusion that antioxidant supplementation, at least as described in the present study, failed to improve cognition in children with DS at the age tested here, but because there was no change in oxidative markers, the study does not inform as to whether behavior/cognition can be improved in these children by amelioration of OS. The authors point out that the dosage of vitamins, metals, and folinic acid were 100 to 200 percent of the recommended daily allowances, which may be considerably lower than doses provided by parents or touted by supplement makers (the authors did not want to risk the possibility of adverse effects that might result from higher dose supplementation). Ellis and colleagues point out that this trial was unusual in that participants were very young children and that this has not generally been the case in other studies. This was a proposed strength of the current study; however, it might also be a shortcoming. The DS phenotype is complex; mental deficits may result from multiple inputs that are age- related. For example, developmental delay might contribute to deficits in children under the age of 2, whereas markers of OS appear to increase with age, especially from adolescence onward (11). Hence, antioxidant supplements in older children might have different outcomes, though this has not been the case with the rather limited trials that have been undertaken previously (5). Aâ lowering or neutralizing therapies (when made available) might prove beneficial. (11)Therapeutic intervention in DS has recently become a topic of considerable interest because of similarities to AD. An amyloid and neurodegenerative phenotype, including pronounced degeneration of cholinergic neurons pathologically indistinguishable from AD, develops in DS adults by the fourth decade of life. Many if not most go on to develop dementia. Much of this is thought to result from triplication of APP and other genes (such as ETS2) (4,12,13) that further upregulate APP expression or affect its metabolism, causing elevation in Aâ levels that persist throughout life. This begs the question: does Aâ contribute to mental retardation? Amyloid plaques generally do not appear in DS until adulthood but lifelong, high levels of soluble or intracellular Aâ might contribute to deficits in synaptic plasticity. The cholinergic deficit shared by DS and AD has piqued interest in the possibility of treating DS with cholinesterase inhibitors. Several small clinical trials have been reported involving donepezil and rivastigmine in children (8 years and older) and in adults with and without an Alzheimer-like progressive dementia. These trials report modest benefits in language, memory, and adaptive behavior (10,14). At least one small clinical trial (currently recruiting at Kings College, London) will be testing the tolerability and efficacy of memantine in DS adults age 40 and over, with and without dementia. Additionally, Costa and colleagues recently showed that acute administration of memantine rescues deficits in fear conditioning in the widely used Ts65Dn DS mouse model (15). Their recent report suggests that deficits in synaptic plasticity in Ts65Dn mice are influenced by reduced calcineurin activity, which can be at least partially corrected by memantine-induced normalization of NMDAR function. In summary, the present study cautions against the use of antioxidant supplements in children with DS. Nevertheless, the possibilities for intervention in mental retardation and DS are likely to become more vivid as an understanding of DS and AD and their intersections continues to grow. References: 1.Ellis JM, Tan HK, Gilbert RE, Muller DP, Henley W, Moy R, Pumphrey R, Ani C, Davies S, Edwards V, Green H, Salt A, Logan S. Supplementation with antioxidants and folinic acid for children with Down's syndrome: randomised controlled trial. BMJ. 2008 Feb 22 2.Salman M. Systematic review of the effect of therapeutic dietary supplements and drugs on cognitive function in subjects with Down syndrome. Eur J Paediatr Neurol. 2002;6(4):213-9 3.Nunomura A, Perry G, Pappolla MA, Friedland RP, Hirai K, Chiba S, Smith MA. Neuronal oxidative stress precedes amyloid-beta deposition in Down syndrome. J Neuropathol Exp Neurol. 2000 Nov;59(11):1011-7 4.Iannello RC, Crack PJ, de Haan JB, Kola I. Oxidative stress and neural dysfunction in Down syndrome. J Neural Transm Suppl. 1999;57:257-67 5.Bar-Peled O, Korkotian E, Segal M, Groner Y. Constitutive overexpression of Cu/Zn superoxide dismutase exacerbates kainic acid- induced apoptosis of transgenic-Cu/Zn superoxide dismutase neurons. Proc Natl Acad Sci U S A. 1996 Aug 6;93(16):8530-5. 6.Odetti P, Angelini G, Dapino D, Zaccheo D, Garibaldi S, Dagna- Bricarelli F, Piombo G, Perry G, Smith M, Traverso N, Tabaton M. Early glycoxidation damage in brains from Down's syndrome. Biochem Biophys Res Commun. 1998 Feb 24;243(3):849-51 7.Fillenbaum GG, Kuchibhatla MN, Hanlon JT, Artz MB, Pieper CF, Schmader KE, Dysken MW, Gray SL. Dementia and Alzheimer's disease in community-dwelling elders taking vitamin C and/or vitamin E. Ann Pharmacother. 2005 Dec;39(12):2009-14 8.Grundman M, Grundman M, Delaney P. Antioxidant strategies for Alzheimer's disease. Proc Nutr Soc. 2002 May;61(2):191-202 9.Kontush K, Schekatolina S. Vitamin E in neurodegenerative disorders: Alzheimer's disease. Ann N Y Acad Sci. 2004 Dec;1031:249-62 10.Spiridigliozzi GA, Heller JH, Crissman BG, Sullivan-Saarela JA, Eells R, Dawson D, Li J, Kishnani PS. Preliminary study of the safety and efficacy of donepezil hydrochloride in children with Down syndrome: a clinical report series. Am J Med Genet A. 2007 Jul 1;143(13):1408-13 11.Venkitaramani DV, Chin J, Netzer WJ, Gouras GK, Lesne S, Malinow R, Lombroso PJ. Beta-amyloid modulation of synaptic transmission and plasticity. J Neurosci. 2007 Oct 31;27(44):11832-7 12.Rachidi M, Lopes C. Mental retardation in Down syndrome: from gene dosage imbalance to molecular and cellular mechanisms. Neurosci Res. 2007 Dec;59(4):349-69 13.Wolvetang EW, Bradfield OM, Tymms M, Zavarsek S, Hatzistavrou T, Kola I, Hertzog PJ. The chromosome 21 transcription factor ETS2 transactivates the beta-APP promoter: implications for Down syndrome. Biochim Biophys Acta. 2003 Jul 28;1628(2):105-10. 14.Heller JH, Spiridigliozzi GA, Crissman BG, Sullivan JA, Eells RL, Li JS, Doraiswamy PM, Krishnan KR, Kishnani PS. Safety and efficacy of rivastigmine in adolescents with Down syndrome: a preliminary 20-week, open-label study. J Child Adolesc Psychopharmacol. 2006 Dec;16(6):755-65 15.Costa AC, Scott-McKean JJ, Stasko MR. Acute Injections of the NMDA Receptor Antagonist Memantine Rescue Performance Deficits of the Ts65Dn Mouse Model of Down Syndrome on a Fear Conditioning Test. Neuropsychopharmacology. 2007 Aug 15 Competing interests: None declared
Nutritional Interventions and the Potential for Type II Errors 14 March 2008
Gregory A Plotnikoff, Medical Director, Institute for Health and Healing Abbott Northwestern Hospital Minneapolis, MN 55407 Send response to journal: Re: Nutritional Interventions and the Potential for Type II Errors	This article failed to address two key issues and thus this report may represent a false negative study. First, vitamin E was not defined. Was it D,L alpha tocopherol? D- alpha tocopherol? combined with succinate or acetate? Mixed (alpha, beta, delta, gamma) tocopherols? Were any tocotrienols present? This lack of precision significantly limits the reader's capacity to assess the appropriateness of this intervention. Vitamin E is a broad, non-specific term for 8 different molecules (four tocopherols, four tocotrienols) with different metabolic by-products, potencies and actions. To further complicate matters, synthetic vitamin E (all-rac-alpha-tocopherol) contains equal amounts of eight different stereoisomers of alpha-tocopherol that have equivalent antioxidant activities but different biological activities. Second, nutritional sufficiency/deficiency was not assessed at baseline. For randomized trials in an era of pandemic vitamin D and omega- 3 fatty acid deficiencies, the reader cannot assume that such confounding nutritional deficiencies were not present in all arms of the study. In this case, there is sufficient evidence connecting these pandemic deficiencies (in both mothers and infants) with impaired central nervous system functioning. We readers do not know if the intervention failed because of more fundamental/confounding issues that limited the intervention's efficacy or if the intervention itself had no efficacy. Classically, Type II errors (false negative studies) occur in underpowered studies, use of the wrong population or presence of referral biases, insufficient time or dose, and use of inappropriate instruments or outcomes measurements. Until now, nutritional issues have rarely been considered. In order to avoid false negative findings in nutritional interventions, all authors, reviewers and publishers must consider the importance of a well-defined intervention and a well-defined starting point. Competing interests: None declared
Antioxidants under the scrutiny of science 21 March 2008
Carlos K B Ferrari, Head Professor of Medical Biochemistry and Genetics Federal University of Mato Grosso (UFMT), Instituto Universitário do Araguaia, Eduardo L França, Adenilda C Honorio-França, Paula C S Souto. Federal University of Mato Grosso (UFMT), Instituto Universitário do Araguaia Send response to journal: Re: Antioxidants under the scrutiny of science	Sir, its well recognized that oxidative, chlorine, and nitrosative stresses can contribute to cell pathology, increasing the risk of more than a hundred of important diseases (1,2,3). However, data from the study of Ellis et al. (4) and many other clinical trials and epidemiological surveys have been failed to support that antioxidant supplementation can materially decrease the risk of pathologies (5-7). It is important to note that an adequate daily dietary intake of fruits, vegetables, legumes and cereals, which present a rich content and diversity of antioxidants is fundamental to hinder free radicals and can contribute to decrease the risk diseases, prolonging human life span (8- 12). Once mitochondrial and peroxissome-generated free radicals are important in cell maintenance and body's defense against infectious diseases and oncogenic cells (9,13-16) indiscriminate use of antioxidant supplements is not recommended today. Better strategies to improve mitochondrial biogenesis and function such as regular practice of physical activities and dietary intake of functional foods should be tested in controlled intervention trials as a promise non- pharmacological strategy in Down's syndrome. References 1)Halliwell B, Gutteridge JMC. Free radicals in Biology and Medicine. Oxford, Oxford University Press, 1999. 2)Ferrari CKB. Oxidative Stress Pathophysiology: Searching for an effective antioxidant protection. Intern Med J 2001; 8(3): 175-84. 3)Nakamura T, Lipton SA. Molecular mechanisms of nitrosative stress- mediated protein misfolding in neurodegenerative diseases. Cel Mol Life Sci 2007; 64(13): 1609-20. 4)Ellis JM, Tan HK, Gilbert RE, Muller DPR, Henley W, Moy R, et al. Supplementation with antioxidants and folinic acid for children with Down's syndrome: randomised controlled trial. BMJ 2008; 336: 594-7. 5)Taylor HR, Tikellis G, Robman LD, McCarty CA, McNeil JJ. Vitamin E supplementation and macular degeneration: randomised controlled trial. BMJ 2002; 325 (7354): 11-4. 6)Liu S, Ajani U, Chae C, Hennekens C, Buring JE, Manson JE. Long-term beta-carotene supplementation and risk of type 2 Diabetes Mellitus. JAMA 1999; 282: 1073-5. 7)Siriwardena AK, Mason JM, Balachandra S, Bagul A, Galloway S, Formela L, et al. Randomised, double blind, placebo controlled trial of intravenous antioxidant (n-acetylcysteine, selenium, vitamin C) therapy in severe acute pancreatitis. Gut 2007; 56: 1439-44. 8)Engelhart MJ, Geerlings MI, Ruitenberg A, van Swieten JC, Hofman A, Witteman JC, Breteler MM. Dietary intake of antioxidants and risk of Alzheimer disease. JAMA 2002; 287: 3223-9. 9)Ferrari CKB. Functional foods, herbs, and nutraceuticals: Towards biochemical mechanisms of healthy aging. Biogerontology 2004; 5: 275-89. 10)Youdim KA, Joseph JA. A possible emerging role of phytochemicals in improving age-related neurological dysfunction: a multiplicity of effects. Free Rad Biol Med 2001; 30: 583-94. 11)Trichopoulou A, Orfanos P, Norat T, Bueno-de-Mesquita B, Ocké MC, Peeters PHM, van der Schouw YT, et al. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. BMJ 2005; 330: 991. 12)Ferrari CKB. Special Article: Functional Foods and Physical Activities in Health Promotion of Aging People. Maturitas 2007; 58(4): 327-39. 13)Ferrari CKB. Free radicals, lipid peroxidation, and antioxidants in apoptosis: Implications for cancer, cardiovascular, and neurological diseases. Biologia 2000; 55(6): 580-90. 14)Botelho ACF, Honorio-França AC, França EL, Gomes MA, Costa-Cruz JM.Phagocytosis of Giardia lamblia trophozoites by human colostral leukocytes. Acta Paediatrica 2006; 95: 438-43. 15)Fang J, Deng D, Nakamura H, Akuta T, Qin H, Iyer AK, Greish K, et al. Oxystress inducing antitumor therapeutics via tumor-targeted delivery of PEG-conjugated D-amino acid oxidase. Int J Canc 2008; 122: 1135-44. 16) Chen Y, McMillan-Ward E, Kong J, Israels SJ, Gibson SB. Oxidative stress induces autophagic cell death independent of apoptosis in transformed and cancer cells. Cell Death Diff 2008; 15: 171-82. Competing interests: None declared
Down's Syndrome and blood flow. 2 April 2008
Les O. Simpson, retired medical research worker Dunedin, New Zealand, 9077 Send response to journal: Re: Down's Syndrome and blood flow.	While it is very likely that much is known about the genotype of Down's people, it seems that there is some unidentified change in the internal milieu which stimulates changes in the shape populations of red blood cells. The unpublished observations which follow indicate that those working in the field of Down's Syndrome might obtain useful information from studies of blood flow using SPECT or Laser Doppler Flowmetry. Through the good offices of a colleague with an interest in Down's Syndrome, 5-drop blood samples, which were fixed immediately, were obtained from children with Down's Syndrome, who lived in Dunedin or Christchurch in New Zealand. Stimulated by the findings from those samples, further samples were obtained from Australia (Toowoomba,Perth) South Africa (Durban) and India (New Delhi). The samples were prepared for and subjected to scanning electron microscopy, and the cells in the resulting micrographs were assessed by red cell shape analysis. The results showed that in contrast to the blood from healthy subjects, there were increased values for flat cells or for cup forms. There was an unexplained regional variation, as while Dunedin samples were dominated by flat cells, Christchurch samples had increased cup forms as the most frequent change. The samples from Durban had about 50% of each change There is good evidence which shows that red cells respond to change in their environment by changing shape, and that blood with changed shape populations filters poorly. Thus it can be expected that shape changed, poorly deformable red cells will reduce the rate of capillary blood flow. In such circumstances tissues may not receive the oxygen and nutrient substrates necessary to sustain normal tissue function. Dysfunction can be expected to become manifest first in those tissues which are most sensitive to oxygen deprivation, such as nerve and muscle tissue and the secreting glands. Changed shape populations of red cells were reported in muscular dystrophy in the early 1970s and in Huntington's Disease in 1977, so the primary observation is not new. In a paper titled, "Red cell shape in health and disease," (1) it was noted that, "The diversity of disorders in which increased percentages of nondiscocytes occur, invites the conclusion that the resulting impairment of capillary blood flow and oxygen delivery is a common pathway in the pathophysiology of symptoms." In 1974 (2) Kury et al reported that prostaglandin E1 improved the fluidity of the red cell membrane. Furthermore it has been found that red cell deformability, as assessed by blood filterability, was improved when the blood levels of prostaglandin E1 were increased by taking at least 4 grams daily of evening primrose oil. This information of the potential benefits of evening primrose oil was included with the results, together with micrographs of the blood cells, which was mailed to the parents of all participants. Although there was little parental response, the two responses received were highly informative. A parent from Toowoomba reported that her son's school teacher had noted that after the boy began to take evening primrose oil, he was able to was able to play basketball for much longer than previously. The mother of a tiny one year old girl, who at the time of blood sample collection was unable to hold her head up, wrote to say that after three months of evening primrose oil supplementation, Rhidima was trying to walk. An attempt to undertake a placebo-controlled trial failed because a lack of participants. As high values for flat cells are a part of the aging process, it could be speculated that as some Down's children had similar values to those aged between 60 and 96 years,(3) this might contribute to the early onset of Alzheimer's disease in Down's people. Even though nothing is known about the factor or factors responsible for the changed red cell shape populations, it seems that by addressing the resulting blood flow problem, the quality of life for Down's people could be improved. References. 1. Simpson LO. Red cell shape in health and disease. IN:Swamy NVC, Megha Singh (eds), Physiological Fluid Dynamics III, Narosa Publishing House, New Delhi,1992. 2. Kury PG, Ramwell PW, McConnell HM. The effect of prostaglandin E1 and E2 on the human erythrocyte as monitored by spin labels. Biochim Biophys Res Commun 1974;56:478-83. 3. Simpson LO, O'Neill DJ. Red cell shape changes in the blood of people 60 years of age and older imply a role for blood rheology in the aging process. Gerontology 2003;49:310-5. Competing interests: None declared
Fortified Baby Formula 19 June 2008
Peter Elliott, Retired 18 Daws Hill Lane,, High Wycombe. HP11 1PW Send response to journal: Re: Fortified Baby Formula	I wondered if the babies in this study were really in need of any additional antioxidants or Folinic acid. Were they perhaps already getting these vitamins and minerals in the fortified baby formula. A quick check of several manufacturers products showed very high levels of antioxidants and folic. Plus a broad range of many other vitamins and minerals. As most of these babies were around age 6 months at entry into the project and age 2 as they left the project they were all most likely getting these fortified baby formula and were indeed getting selenium, zinc, Vit. A, Vit.C, and folic at or above the levels used for this studies. Only the Vit.E was significantly higher in the therapy compared to the intake from baby formula. This would mean all the babies including the babies getting the placebo were actually getting antioxidants and folic at or above the levels used in this therapy (apart from the Vit.E). Any study needs to first verify nutritional deficiency and a need for suppliments. And then verify that a proposed therapy is having an influence on the biochemistry. There is also a need to evaluate this theraputic dose rate to ensure it is significant when measured against the normal dietary intake of these same antioxidants and folic. It might be argued that the therapy did increase the intake of the vitamins and minerals but there is no reason to suppose suppliments in excess of what is needed will result in any benefits at all. Hence you might expect every child to do equally well and this was the outcome of this study. Vitamin E certainly was tested at high levels on half the babies and showed no benefit. Was this synthetic E or was it natural E? This is important information. Competing interests: None declared