INTEGRITY ASSESSMENT IN THE HEALTH SECTOR UNDP Project for the Jordanian Anti Corruption Commission Drafted by Dr Rania Bader, BSc, MSc "Health and Pharmaceutical Policies Consultant" Drafted by Dr Rania Bader, BSc, MSc "Health and Pharmaceutical Policies Consultant" APPENDIX C– HEALTH TECHNOLOGY ASSESSMENT/ HTA APPENDIX D– MANGAMENT INFORMATION SYSTEM / HAKEEM
Pcrm.bizA Natural Approach to Menopause Every day, in hundreds of doctors' offices, the same Study (HERS) confirmed that hormones did not reduce the conversation takes place between women going through risk of heart problems in postmenopausal women with heart menopause and their doctors. The doctor writes out disease. In fact, their risk of blood clots doubled and their need a prescription for estrogen pills or patches, saying they will for gallbladder surgery increased as well.2 replace the hormones her body ought to be making. They will Estrogen supplements not only increase the risk of breast cure her hot flashes and slow her bone loss. The patient asks if cancer, blood clots, strokes, and heart disease, but also appear the pills cause cancer. The doctor acknowledges that there is to increase the risk of dementia3 and uterine and ovarian an increased risk of uterine and breast cancer, but argues that cancer (when taken without progestin).4,5 These hormone the benefits are worth taking the chance.
supplements may also cause high blood pressure, gallstones, Other risks enter into the discussion, such as heart disease, vaginal bleeding, nausea, weight gain, breast tenderness, skin strokes, and blood clots. Women who have seen friends or discolorations, headaches, and depression. relatives die of these conditions might not find this very Fortunately, hormone replacement therapy use has decreased reassuring. They may have menopausal symptoms, and they since the release of the WHI study in 2002,6 and more women would like a solution. But they are looking for something safe, understand the risks of HRT.7 Unfortunately, however, some something that doesn't cause more problems than it solves.
doctors continue to prescribe these hormones. Take heart: There are dietary steps and other lifestyle Fortunately, there are healthier solutions for the problems changes that can make menopause much more manageable. associated with menopause.
They are better for your bones than estrogen prescriptions could ever hope to be, and they accomplish these things Natural Changes
without the side effects of estrogens.
At around age 50, the ovaries stop producing estrogens. Premarin is a commonly prescribed estrogen preparation The adrenal glands (small organs on top of each kidney) from Wyeth Pharmaceuticals. Although doctors sometimes continue to make estrogens, as does fat tissue. But the ovaries describe it as "natural" for women, it is actually a horse have produced the greatest share of the body's estrogens for estrogen. On farms in the United States and Canada, mares decades, and when they quit, the blood levels of estrogens are impregnated and then confined from the fourth month drop dramatically.
through the end of their 11-month pregnancy so their urine Many women go through this change feeling fine, both can be gathered in a collection harness called a "pee bag." physically and psychologically. Nonetheless, some women After they give birth, the mares are reimpregnated. Their are bothered by symptoms, including hot flashes, depression, foals usually end up as horse meat and the urine estrogens irritability, anxiety, and other problems.
are packed into pills. The trade name "Premarin" is simply a condensation of the words "pregnant mares' urine"—hardly Does Food Play a Role?
a natural substance for human beings to swallow. While Premarin contains estradiol and estrone, two types of estrogen Some have suggested that menopause was much easier for Asian women than for Westerners—at least while women that are made in humans, it also contains an enormous followed traditional, mostly plant-based diets. Hot flashes have amount of equilin, a horse estrogen that never occurs at all been reported by only about 10 percent of women in China,8 17.6 percent of women in Singapore,9 and 22.1 percent of In 2002, the Women's Health Initiative (WHI), which was women in Japan.10 In contrast, it is estimated that hot flashes studying the effects of combined estrogen and progestin use are experienced by 75 percent of women over the age of 50 in in postmenopausal women, was halted three years early. the United States.11 Whether these differences might be partly Researchers had observed an increased risk of breast cancer, due to reluctance in reporting symptoms among Asians is not potentially deadly blood clots, strokes, and heart disease in entirely clear. And as Asia's diets gradually westernize, these women taking hormones (compared with those in the placebo differences are likely to disappear anyway. group who remained drug free).1 Again, in 2002, the nearly But we do know that, throughout their lives, Western seven-year-long Heart and Estrogen/Progestin Replacement women consume much more meat, and about four times as much fat, as women on traditional Asian rice-based diets, and shown little evidence that they alleviate symptoms, however, only one-quarter to one-half the fiber. For reasons that have this topic still needs much research16. Dietary supplements never been completely clear, a high-fat, low-fiber diet causes a are not regulated by the Food and Drug Administration, and rise in estrogen levels. Women on higher-fat diets have mea- it is important to talk to your doctor before taking any kind surably more estrogen activity than do those on low-fat diets. of supplement.
At menopause, the ovaries' production of estrogen comes to a For those women who are considering hormone supplements, halt. Those women who have been on high-fat diets then have some preparations may be safer than others. Estrogens a violent drop in estrogen levels. The drop appears to be less commonly prescribed by physicians contain significant dramatic for Asian women who have lower levels of estrogen amounts of estradiol, which is one of the forms of estrogen that both before and after menopause. The resulting symptoms are has scientists and many postmenopausal women concerned much milder or even nonexistent.
about cancer risk. A different estrogen, estriol, appears to More evidence of the diet link comes from a fascinating be safer. The best evidence indicates that estriol does not study by a medical anthropologist from the University of increase cancer risk.17,18,19,20 Plant-derived transdermal creams California who interviewed Greek and Mayan women about containing estriol and smaller amounts of other estrogens are their experiences of menopause.12 available without a prescription. The estrogens pass through The Greek women were subsistence farmers. Menopause the skin and enter the blood stream, reducing menopausal occurred at an average age of 47, compared with an average symptoms. Creams containing pure estriol must be ordered by age of more than 50 in the United States. About three-quarters doctors, not because they are more dangerous (they are not), of the Greek women had hot flashes, but they were considered but because the process of concentrating them qualifies them normal events and did not cause the women to seek medical as drugs, rather than natural preparations. If these creams are used, they should be accompanied by progesterone to reduce The Mayan women lived in the southeastern part of Yucatan, the risk of uterine cancer and use should be monitored by a Mexico. Menopause occurred earlier than in Greece or North physician. Regrettably, less research has been done on the use America, at an average age of 42. Unlike the experience of of estriol than estradiol. Greeks and Americans, hot flashes were totally unknown among Mayans, and, like the Japanese, they have no word Natural Solutions for Dryness
for them. Midwives, medical personnel, and the women At menopause, vaginal blood flow falls. Dryness and themselves reported that hot flashes simply do not occur, nor irritation can occur, and bacteria infections that pass to are they mentioned in books on Mayan botanical medicine.
the urinary tract are more likely.
The difference between Americans and Greeks and other What is to be done? First of all, even after the ovaries stop, Europeans on the one hand, for whom hot flashes are common, the adrenal glands and the fat tissue continue to contribute and the Mayans and Japanese on the other, for whom hot to estrogen production after menopause. In addition, flashes are rare or unknown, appears to be diet. The Mayan phytoestrogens in plants provide weak estrogen effects. Soy diet consists of corn and corn tortillas, beans, tomatoes, products, such as tofu, tempeh, and miso, contain huge squash, sweet potatoes, radishes, and other vegetables, with amounts of these natural compounds. very little meat and no dairy products. Like the traditional The plant-derived estrogen and progesterone creams Japanese diet, it is extremely low in animal products and described above can be helpful. Used on a regular basis, these low in fat in general. The Greek diet, while rich in vegetables creams maintain a moist vaginal lining. However, please note and legumes, also contains meat, fish, cheese, and milk, as that they should not be used as a sexual lubricant. Estrogen does the cuisine of other countries in Europe and North cream is a medication, not a lubricant, and it goes through America. Animal-based meals affect hormone levels rapidly any skin it touches, including men's. Many women prefer to and strongly, and undoubtedly contribute to the menopausal avoid hormone creams entirely and use ordinary lubricants or problems that are common in Western countries.
Treating Hot Flashes
The Psychology of Menopause
In addition to a low-fat, vegetarian diet, which is strongly recommended for women who are experiencing hot flashes, Hormone shifts can affect moods. It can be disturbing to find yourself feeling uncharacteristically nervous or regular aerobic exercise helps.13 A vigorous walk every day depressed or having memory lapses. Sometimes these feelings or so, or any equivalent physical activity, seems to ease hot can even strain your relationships with others. It helps to know that the psychological effects of menopause are temporary. In A number of herbal and dietary supplements claim to all likelihood, you'll soon get back on an even keel. Here are the alleviate menopausal symptoms. Some studies have shown most common psychological accompaniments of menopause.
that black cohosh13,14,15 and soy,13,14 to a lesser extent, may help. Anxiety. Women who have never had a problem with
Trials of vitamin E, dong quai, and other such treatments have anxiety before may become more self-conscious and worried about minor events. In some cases, panic attacks occur. Mental daily calcium requirement by about 160 milligrams.26 For health professionals have a variety of effective treatments. Many postmenopausal women, decreasing sodium intake from the people feel much better just knowing what the condition is.
U.S. average (3.4 grams per day) to a low sodium diet (< 2 The most important piece of advice is not to let anxiety grams per day) has been shown to improve skeletal health.27 restrict your activities. When anxiety or panic disorders cause Grains, vegetables, fruits, and beans are very low in sodium people to avoid stressful situations, the result can be an ever- unless salt is added to them. Snack foods, canned foods, dairy tightening leash that keeps them from enjoying life. Anxiety products, and meat tend to drive up the amount of sodium in can lead to avoidance of many aspects of normal life. Prompt the diet.
treatment prevents this.
3. Caffeine. Whether it comes in coffee, tea, or colas,
Depression and Irritability. Depression can be caffeine is a weak diuretic that causes calcium loss via the
a problem for menopausal women.21,22 Irritability is also kidneys.28 Caffeine intakes of >300 mg per day have been common.23 When considering treatment for depression, shown to accelerate bone loss in elderly postmenopausal irritability, or anxiety, it is important to explore the full range women.29 of available options. The first step is to get your diet in order 4. Tobacco. Long-term smokers have 10 percent weaker
and to get regular exercise to help stabilize hormone shifts bones and a 40 percent higher risk of fracture.30 Even second- and reduce physical symptoms that can aggravate mood hand smoke in the home can negatively affect bone density.31 problems. Psychotherapy can be very useful, and new short- 5. Sedentary lifestyle. Bones that have nothing to do
term techniques have demonstrated their effectiveness at lose their strength,32 and low physical activity is a risk factor considerably less investment than is demanded by traditional for osteoporotic bone fractures.33 For optimal bone health, therapies. New antidepressants and antianxiety drugs have adults should aim for at least 30 minutes of physical activity fewer side effects than older medications.
most days, preferably daily, and include weight-bearing and Poor Memory and Concentration. Some women strength training exercises.34
find that menopause brings occasional memory lapses, often related to reduced ability to concentrate. This can be upsetting Healthy Calcium Sources
and annoying, but happily it seems to go away on its own When you eliminate these calcium-wasters, you need less calcium in your diet. However, you will always need Keeping or Restoring Strong Healthy Bones
some calcium. The World Health Organization recommends 800 mg per day for post-menopausal women on a diet low in steoporosis—thinning of the bone tissue—is common, animal protein.35 particularly among Caucasian women, after menopause. The cause is not an inadequate calcium intake, ordinarily. The Although many people try to get their calcium from problem is abnormally rapid calcium loss, aggravated by the milk, only about 30 percent of calcium in dairy products is following five calcium wasters: absorbed.36 The remaining 70 percent never makes it past 1. Animal protein. When researchers feed animal the intestinal wall and is simply excreted with the feces. Milk
protein to volunteers and then test their urine a little later, it products also contain lactose sugar, animal proteins, and is loaded with calcium, which comes from their bones. Here's frequent traces of antibiotics and other contaminants.
why. A protein molecule is like a string of beads, and each The most healthful calcium sources are greens and beans. "bead" is an amino acid. When protein is digested, these"beads" Green leafy vegetables are loaded with calcium. One cup of come apart and pass into the blood, making the blood slightly collard greens has 226 milligrams of calcium. What's more, acidic. In the process of neutralizing that acidity, calcium is the calcium in most green leafy vegetables is more absorbable pulled from the bones. It ends up being lost in the urine. A than the calcium in milk. An exception is spinach, which tends report in the American Journal of Clinical Nutrition showed to keep its calcium to itself. Beans, lentils, and other legumes that when research subjects eliminated meats, cheese, and eggs are also loaded with calcium. If you make green vegetables from their diets, they cut their urinary calcium losses in half.24 and beans regular parts of your diet, you'll get two excellent Another study showed that a high ratio of animal protein to sources of calcium. Calcium-fortified orange juice contains vegetable protein in the diet increases bone loss and risk of more calcium than milk, and it is in the form of calcium fracture in postmenopausal women.25 Switching from beef to citrate, which is much more readily absorbed than that in milk chicken or fish does not help, because these products have as or in calcium carbonate supplements. much animal protein as beef, or even a bit more.
You don't need to eat six cups of greens or huge servings 2. Sodium (salt). If you throw salt on a slippery sidewalk, of beans to get enough calcium. A varied menu of vegetables
it dissolves the ice; if you sprinkle it on your food, it can and legumes can easily give you all you need, and the amount dissolve your bones, albeit by a different mechanism. Salt your body needs is far less when you steer clear of meats and apparently increases calcium losses via the kidneys. For an the other calcium depleters. average person, cutting sodium intake in half reduces the TABLE OF HEATLHFUL CALCIUM SOURCES
CALCIUM CONTENT IN MILLIGRAMS
Black turtle beans (1 cup, boiled) Broccoli (1 cup, boiled from frozen) Brussels sprouts (1 cup, boiled) Butternut squash (1 cup, boiled) Celery (1 cup, boiled) Chick peas (1 cup, canned) Collards (1 cup, boiled) Figs, dried (10 medium) Great Northern beans (1 cup, boiled) Green beans (1 cup, boiled) Kale (1 cup, boiled) Kidney beans (1 cup, boiled) Lentils (1 cup, boiled) Lima beans (1 cup, boiled) Mustard greens (1 cup, boiled) Navel orange (1 medium) Navy beans (1 cup, boiled) Nondairy milk (1 cup, fortified soy or rice) Oatmeal (1 cup, prepared instant Onions (1 cup, boiled) Orange juice, calcium fortified (1 cup) Pinto beans (1 cup, boiled) Raisins (1/2 cup) Soybeans (1 cup, boiled) Sweet potato (1 cup, boiled) Turnip greens (1 cup, boiled) Vegetarian baked beans (1 cup) White beans (1 cup, boiled) Source: Pennington JA, Douglas JS. Bowes and Church's food values of portions commonly used. 18th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005.
on vaginal flora and cytology and urogenital symptoms in the post-menopause. s sunlight touches the skin, it turns on the natural 20. Gerbaldo D, Ferraiolo A, Croce S, Truini M, Capitanio GL. Endometrial morphology production of vitamin D, which helps your digestive tract after 12 months of vaginal oestriol therapy in post-menopausal women. Maturitas. absorb calcium from foods and makes your kidneys hold onto 21. Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL. Risk for new onset of it as wel . For those who get infrequent sun exposure, a vitamin depression during the menopausal transition: the Harvard study of moods and cycles. D supplement or multivitamin containing vitamin D may be Arch Gen Psychiatry. 2006 Apr;63(4):385-90.
22. Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and necessary. For women < 50 years old, 5 mcg (200 IU) per day menopausal status with depressed mood in women with no history of depression. is recommended; for women 51-65 years, 10 mcg (400 IU); Arch Gen Psychiatry. 2006 Apr;63(4):375-82.
and for women >65 years, 15 mcg (600 IU).
23. O'Bryant SE, Palav A, McCaffrey RJ. A review of symptoms commonly associated 35 Higher doses of with menopause: implications for clinical neuropsychologists and other health care vitamin D can be toxic and should be avoided. providers. Neuropsychol Rev. 2003 Sep;13(3):145-52.
24. Remer T, Manz F. Estimation of the renal net acid excretion by adults consuming diets The Bottom Line
containing variable amounts of protein. Am J Clin Nutr. 1994;59:1356-61.
25. Sellmeyer DE, Stone KL, Sebastian A, Cummings SR. A high ratio of dietary animal enopause is a normal part of life, not a diagnosis. And to vegetable protein increases the rate of bone loss and the risk of fracture in postmenopausal women. Am J Clin Nutr. 2001;73:118-22.
there are healthful, natural ways to manage the changes 26. Nordin BEC, Need AG, Morris HA, Horowitz M. The nature and significance of it can bring. A low-fat, vegetarian diet, combined with regular the relationship between urinary sodium and urinary calcium in women. J Nutr. physical activity, can help women reduce the symptoms of 27. Carbone LD, Barrow KD, Bush AJ, et al. Effects of a low sodium diet on bone menopause. While hormone replacement therapy increases metabolism. J Bone Miner Metab. 2005;23(6):506-13.
cancer and heart disease risk, these recommended healthy 28. Massey LK, Whiting SJ. Caffeine, urinary calcium, calcium metabolism and bone. J lifestyle changes actually reduce the risk of these illnesses, as 29. Rapuri PB, Gal agher JC, Kinyamu HK, Ryschon KL. Caffeine intake increases the rate well as other menopause related problems.37 of bone loss in elderly women and interacts with vitamin D receptor genotypes. Am J Clin Nutr. 2001 Nov;74(5):694-700.
30. Hopper JL, Seeman E. The bone density of female twins discordant for tobacco use. N Engl J Med. 1994;330:387-92.
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Antibiotic susceptibility of potentiAlly probiotic LactobaciLLus strAins JunhuA hAna, DAhuAn chena, shAnshAn lic, Xingfeng lia, Wen-Wen Zhoud, bolin ZhAngb,*, yingmin JiAa,* aCollege of Biological Science and Engineering, Hebei University of Science and Technology, Shijiazhuang, Heibei, 050018, China bSchool of Biological Science and Biotechnology, Beijing Forestry University, Beijing, 100083, China